Lectures on diseases of the nervous system, especially in women

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LECTURES

DISEASES OF THE NERVOUS SYSTEM,

ESPECIALLY IN WOMEN.

BY

S. WEIR MITCHELL, M.D.

'5

MEMBER OP THE NATIONAL ACADEMY OF SCIENCES;
PHYSICIAN TO THE ORTHOP-(EDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE

NERVOUS SYSTEM ;

VICE-PRESIDENT OP THE PHILADELPHIA COLLEGE OF PHYSICIANS;

MEMBER OP THE NEW YORK ACADEMY OF MEDICINE J

HONORARY CORRESPONDING MEMBER OP THE BRITISH MEDICAL ASSOCIATION ;

HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY;

FOREIGN ASSOCIATE OP THE ROYAL MEDICAL SOCIETY OF NORWAY;

AUTHOR OF A TREATISE ON INJURIES OF NERVES, ETC. ETC.

SECOND EmTION", KEYISED AND ENLARGED,

WITH FIVE PLATES.

PHILADELPHIA:

LEA BROTHERS & CO.
1885.

Entered according to the Act of Congress, in the year 1885, by

LEA BROTHERS & CO.,
in the Office of the Librarian of Congress. All rights reserved.

DORNAN, PRINTER

DEDICATED TO

J. HUGHLINGS-JACKSON, M.D., F.R.S.

WITH WARM PERSONAL REGARD,

IN GRATEFUL ACKNOWLEDGMENT

HIS SERVICES TO

THE SCIENCE OF MEDICINE.

PREFACE TO SECOND EDITION.

The book has been long out of print, but only
of late have I found time to prepare a second
edition.

I have altered considerably some of the
early lectures, and have added others on the
difficulties of diagnosis in hysterical diseases of
joints, on the relations of hysteria to organic
disease of the spine, and on hysterical disorders
of the rectum.

PREFACE TO FIRST EDITION.

The lectures which compose this volume deal
chiefly with some of the rarer maladies, or forms
of maladies, of women. Many of them are original
studies of well-known diseases, and others deal
with subjects which have been hitherto slighted
in medical literature or which are almost un-
known to it.

I desire to express my thanks for very valuable
aid to my colleague Dr. Whaeton Sinkler, to
Professor Horatio C. Wood, to Dr. Louis Starr,
and especially to Dr. Morris J. Lewis.

CONTENTS.

LECTUEE I.

THE PARALYSES OE HYSTERIA.

PAGE

Paraplegia — Hemiplegia — Bilateral hemiplegia . . .13

LECTUEE II.

HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS.

Briquet's hysterical ataxia — New forms of hysterical ataxia —
Forms of paresis ......... 39

LECTUEE III.

MIMICRY OE DISEASE.

Causes of mimicry — The hysterical state — General nervous-
ness— General failure of health — Psychic peculiarities —
Natural mental and moral conditions favoring mimicry of
disease — Imitative vomiting — Imitative palsj' — Mimicry of
pain — Imitative epilepsy — Imitative meningitis — Epidemic
of rhythmic chorea ........ 55

LECTUEE IV.

MIMICRY OF DISEASE,

Hysteria in childhood — Simulated vomiting — Simulation of
hip-joint disease — Autobiographical confessions . . .81

X CONTENTS.

LECTUEE Y.

PASE

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN.

Rotatory spasms — Functional spasms — Strychnic spasms —
Spasms on change of position — Local spasms simulating
tumors — In the pectoral muscles — In the walls of the ab-
domen— In the gastrocnemius — Hysterical athetosis. . 96

LECTURE VI.

TREMOR.

Hysterical tremor — Nervous tremor with organic disease of
the spine — Alcoholic tremor in nervous women . . .114

LECTURE VII.

CHRONIC SPASMS.

Chronic spasm with simulation of local injury of ulnar nerve
— Chronic spasm of leg — Contracture of leg muscles —
— Treatment of hysterical contractions — Section of tendons
— Simulated contractions — Simulation of contractions and
of disease of ulnar nerve — Chronic spasmodic ptosis . . 123

LECTURE VIII.

CHOREA OF CHILDHOOD.

The relations of the chorea of childhood — To season — To
climate — To locality — To race — Forms of chorea . . 137

LECTURE IX.

HABIT CHOREA.

Definition— Cases of habit chorea— Relatlo to chorea of
childhood — Treatment 1-^6

' CONTENTS. XI

LECTUKE X.

PAGE

DISORDERS OF SLEEP IN NERVOUS OR HYSTERICAL PERSONS.

Sensory shocks — Emotional shocks — Irregular motor dis-
charges— Nocturnal functional hemiplegia — Respiratory
failures in sleep ......... 163

LECTURE XI.

VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERTOUS OR

HYSTERICAL.

Pulse in hysteria — Agitation of heart followed by apparent
death — Eccentricities of pulse in the hysterical — Palpita-
tion of heart with flushing of face — Palpitation of heart
with pallor of face — Surface ischsemia — Vaso-motor par-
alysis in the limbs or the face — Extreme vaso-motor
paralysis of the whole vascular system of the abdominal
cavity — Respiratory peculiarities of hysteria — Case of rapid
respiration in man from wound ...... 184

LECTURE XIL

HYSTERICAL APHONIA.

Paralysis of laryngeal muscles — Failure of coordination in
the various organs which combine to produce speech . . 208

LECTURE XIII.

HYSTERICAL JOINTS.

Typical case — Hysterical knee with plastic infiltration of con-
nective tissues outside of the capsule 218

Xll CONTENTS.

LECTURE XIV.

PAGE

HYSTERIA AND ORGANIC DISEASE OF THE SPINE.

Old cases of hysteria — Unusual case with spinal disease . 227

LECTURE XY.

GASTRO-INTESTINAL DISORDERS OF HYSTERIA.

Comparative rarity of hystero-epilepsies in America —
Difficulty of feeding hysterical women — Troubles as to
mastication — Eorms of dysphagia — Hysterical anorexia —
Hysterical vomiting — Hysterical fasting .... 238

LECTURE XYI.

THE RECTUM AND DEFECATION IN HYSTERIA.

Irritable rectum — The paretic rectum — Anaesthesia of rectum
— Incoordination in defecation — Painful rectum — Anal
spasm . .... . . . . . • • 252

LECTURE XVII.

THE TREATMENT OF OBSTINATE CASES OF NERVOUS EXHAUS-
TION AND' HYSTERIA BY SECLUSION, REST, MASSAGE, ELEC-
TRICITY AND FULL FEEDING.

Character of cases needing this treatment — Seclusion —
Nurses — Uterine disease — Ovarian disorders — Seclusion —
Rest — Massage — Electricity — Mode of feeding . . .265

DISEASES

OF THB

NERVOUS SYSTEM,

ESPECIALLY IN WOMEN.

LECTURE I.

THE PARALYSES OF HYSTERIA.

The case to which I drew your attention at mj
last clinic is here again, a girl, rather wanting in the
signs of sexual ripeness, although sixteen years old.
You will recall the fact that she lost the use of the
right arm hecause of having been alarmed. The
scare brought on what every woman knows as an
attack of hysterics — our ancestors called it the
vapors. The girl cried and laughed by turns, and
then had a slight fit, on coming out of which she
could no longer lift her right arm, or rather she
could lift it but a few inches. On finding this to be
the case, she grew much concerned, and by and by
could not lift it at all, the idea that it could not be
raised helping, as is apt to be the case, to make the
trouble worse. There seems to have been no deceit,
but perhaps the first feebleness may have been slight,
and the power of her belief in her want of force

14 DISEASES OF THE NERVOUS SYSTEM.

great, and this is rather the more likely since, as you
saw, I raised the arm and said, " Now you can keep
it up," which she did. You see that it seems again
palsied. A new order restores it, and she lifts it
without much effort, having won a belief in my
being able to aid her. I send her away with a
lightly uttered word or two as to the use of the hot
iron, if she again loses power. The warning may
answer, or may not. We had a case very like this
two years ago. I believe it got well.

We see here among the ill-fed, needy, and wor-
ried, a good many cases of hysterical loss of power,
and I meet a yet larger number among women of
the upper classes, in whom the disease is caused by
unhappy love affairs, losses of money, and the daily
fret and wearisomeness of lives which, passing out
of maidenhood, lack those distinct occupations and
aims which, in the lives of men, are like the steady-
ing influence of the fly-wheel in an engine.

A yet more common cause of hysterical disorder
is to be met with among the young persons who
frequent the colleges for women. Every year brings
me a fair contingent of patients from these schools;
and I have asked myself over and over why it is that
these places produce so much disease which ought
to be avoidable. As our society is constituted, it is
clear that women must have opened to them the
higher grades of instruction ; and yet something
must clearly be done to avoid the penalties which
hard study, class competitions, and the emotional
stimulus women bring to their work, are apt to
produce.

PAEALYSES OF HYSTEEIA. 15

Something might be done by a careful medical
examination of the fitness of girls entering colleges.
Their power to work during and just after men-
struation should be inquired into, and their early
months of college work should be carefully watched.
Above all, their eyes ought to be examined, because
numerous women become ill from the strain of brain-
work done with imperfect vision. Moreover, these
inspections should be repeated at reasonable intervals.

Let me admit in passing that, at Yassar and some
other schools, the machinery and organization for the
care of the physical and mental health of students
exists ; but it does not seem to work satisfactorily.
The reason is only too clear. The general sense —
shall I say the prejudices — of such groups of women
is opposed to conceding the belief held by physi-
cians that there are in the physiological life of
women disqualifications for continuous labor of mind.
Public sentiment is in women's colleges against this
belief, and acts as a constant goad for women at
times unfit to use their brains. If ever the horrible
system of coeducation of the sexes becomes more
general, this difficulty will, of course, be mischiev-
ously emphasized by the modest dislike of the weaker
girls to exhibit, at intervals, signs of failure, or to
excuse themselves from tasks which they cannot
competently pursue alongside of the male, who is
not weighted by the occasional need to plead any
form of recurrent disability.

It is my present wish to speak of some of the
many kinds of hysterical paralysis, and to dwell far
more freely on methods of treatment than upon

16 DISEASES OF THE NEKVOUS SYSTEM.

minute details in the natural history of these dis-
orders. I do this chiefly because as regards treat-
ment I hold very positive opinions, and because
these opinions have, I believe, been amply justified
by happy results, some of which are familiar enough
to those who have followed my practice.

The group of instances of lessened power which
I shall here discuss will include the usual forms of
hysteric paraplegia and hemiplegia, and that which
I shall call double hemiplegia. I shall not attempt
to cover the whole range of hystero-palsies, but seek
chiefly so to define a certain number as to allow me
to speak of their treatment. I shall also describe
four forms of seeming loss of power, only one of
which is essentially hysterical in nature, and not
found elsewhere with the same features. I allude
to hysterical motor ataxia.

The others are palsy from the rule of an idea,
general paresis, and consciously mimicked palsy.

All three of these may be and are seen outside of
hysteria, but they find in it a fertile soil, and are
none the easier to treat when they are masking in
this disguise.

One of the chief troubles in clearly knowing and
in dealino; with all of these forms of disease is due to
the fact that in most cases, and to some extent, they
may exist in union. The case of palsy may be partly
real, partly pure weakness, partly loss of power from
want of belief in being able to move; or conscious
mimicry may be added to palsy or to the forbidding
influence of a regnant idea, or to the true hysteric
palsy may be joined ataxy of motion. For such vex-

PARALYSES OF HYSTERIA. 17

ing marriages of disorders, and for their offspring of
doubt, we must be ready and watchful. They make
the true limits of hysteric lack of power hard to de-
fine, hard to treat, full of surprises, and unfailing in
interest and variety. Take this for an instance : You
have a case of extreme hysteric paresis to treat. As
a rule, it is readily cured. You predict a clear and
happy future. As time wears on the mere weakness
is gone, the limbs are plump again, the cheek red,
and then you may find, if you have not been careful,
as I have found, that hidden in the mere weakness
there is a distinct amount of motor palsy — a mild,
one-sided loss of power — a true hysteric palsy, and
not at all easy to cure. I shall pick for you, out of
my note-books, cases of each of the forms of disease
I have just spoken of, and shall try to make plain to
you how I treat them. There were once no cases so
much dreaded by me. There are now none to which
I go with so much pleasure, I am sure that I treat
them to-day with a success I could not once have
gained, and I think that what success I have had has
been due to more exact ideas as to what is needed,
and that unflinching purpose and action which grow
out of distinct views.

Let us take first a case of paraplegia — less common
than hemiplegia and more difficult to relieve. The
example I shall quote for you is the more interesting
because of its having ended in death.

Mrs. C, set. 36, a strong woman, and in all ways
well, lost by sudden death a child and her husband.
Thus having cast on her the care of a large estate,
loaded with many burdens, she began to show excess

2*

18 DISEASES OF THE NERVOUS SYSTEM.

of anxiety as to her affairs, and from being sweet
of temper became abrupt and full of unreasonable
doubt as to her advisers. The worry brought with
it speedy loss of blood globules, and as she was a
woman who flowed very freely each month, all these
causes together began to tell. This is the kind of
thing we see much of in medicine. The books say
this, that, or the other causes hysteria. In practice
it is usual to find two or three causes — acting to
assist one another. This woman was quite ready for
an outbreak of some form of nerve trouble, when of
a sudden she met the final blow in the form of a
telegram. The news it bore was neither good nor
ill, but by evil luck the writing looked like that of
her dead husband, and she began to laugh with that
strange want of appropriateness in emotional expres-
sion so common in the nervous. Awaking next day
her legs seemed heavy, which caused her great alarm.
At once, as she told me, the fear of palsy arose in
her mind, and haunted her the more as, day by day,
the feebleness grew worse. She was in Germany
when taken ill, and seems to have been looked upon
as suffering from an organic malady, for she was
treated with nitrate of silver and the hot iron. Then
as she failed to get relief anywhere, she was sent
from one spa to another with a skill which as yet we
are fortunately far from being able to reach.

St. Moritz, Schwalbach, Vichy, Loueche, and
springs of less note, had each their turn, after the
European fashion, until, in despair, she was carried
back to America, where I saw her often and until
the close of her life.

PAEALYSES OF HYSTERIA. 19

This was what I found : A woman of 36, height
5 feet 2 inches, weight 170 lbs., flabby, and thin-
blooded, with healthy heart, lungs, and kidneys. On
the left side of the vagina was felt a tumor about the
size of a walnut. It was very tender, and firm pres-
sure on it gave rise to nausea and distress down the
left leg. I had no doubt that this growth w^as a dis-
placed ovary, but despite this change of place, the
left iliac fossa, both the skin and the parts reached
by deeper pressure, was tender to touch. Was it
ovarian tenderness ? Hardly, in this case. I have
been told by Dr. Goodell that he has seen this same
sensitiveness in other instances where the ovary had
been displaced, and probably too much has been and
is made of this symptom. The tenderness in Mrs.
C.'s case was isolated, as is not unusual, and all about
it up to the waist and down to the feet the bod}^ was
without sense of touch or pain, or of heat and cold.
In tracing this defect upwards it was found to cover
the left breast, but this was so to-day, and then to-
morrow it was less, the upper limit ranging from the
navel to the left armpit.

Motor power was failing when I first saw her, but
this had been the case before, and had been followed
by a change for the better.

The plan pursued in treating the case was one to
which I groped my way a few years ago. My patient
was very thin-blooded, and yet very fat. Such cases,
for some reason not clear to me, are more hard to
redden than are those of thin people in like states of
blood. But if you can safely cause these persons to
lose flesh, as they are helped to remake it, you may

20 DISEASES OF THE NERVOUS SYSTEM.

sometimes redden them with ease, and to raise the
number of blood globules to the normal is usually to
lift a woman above that low level of health, which
is one, at least, of the factors of hysteria.

Mrs. C. was, when first seen by me, sitting up most
of the day, and sewing, writing, and the like, when
not too nervous. I put her in bed, and employing
as a diet milk alone, mixed with a little rice-water or
barley-water, I began to lessen the amount given,
until, using less than a quart a day, her weight fell
off at the rate of about a quarter to a half pound a
day. When she showed signs of weakness I added
beef soup to the diet for a day or two, and thus in
one month brought down her weight some twenty-
four pounds. This could not with safety have been
so quickly done had not the patient have been kept
in bed. Then the milk was by degrees increased.
Raw beef and vegetables were added, malt extract
was used before meals, a little red wine or champagne
was allowed, and iron was given freely, the feeding
being frequent. When I made the increase in diet
I began to arouse sensation by the use of the wire
brush and induction currents.

E'ow in common palsies, or in those from nerve
wounds, feeling is apt to come back first, motion
last; but in hysteric palsies, as I think, the gain in
active motion may go on, and even reach a useful
amount while yet the lack of feeling rests as it was
when the treatment began. Just this change took
place in Mrs. C. : She grew brighter, and more
happy, gained in color and flesh, and began to move
her legs. In a month after she reached full diet she

PAKALYSES OF HYSTEEIA. 21

could walk with some trouble, and about this time
the sense of touch showed signs of betterment, but
the power to feel pain was unchanged, and, in fact,
was never complete in the left leg.

I^ext began a plan of steady, urgent calls upon her
for increase of the use of her limbs, so that before
long she was able to walk out of doors. At this point
I fear there was a mistake made in the treatment.
Thinking the battle won I pushed her too hard, and
one day after walking much further than usual she
felt an excess of fatigue. Returning home she gave
out of a sudden, and the morning after was again
hardly able to stir either leg. I may pause here to
repeat as to this matter a warning I have often given.
It is to urge on you the utmost care as to allowing a
hysterical patient on the way to health — I mean, of
course, one who has lost power — to do more each
day than fulfil the ordered task of that day. Most
cases of hystero-palsies are easily tired, and it is
almost sure to be the case that they cannot make a
long effort without showing the effect in some way;
moreover the mental results of extreme tire are to be
feared, because any positive, real sensation is apt to
become the peg, so to speak, on which the patient
may hang the complement of a larger and less real
sensation.

More slowly this time Mrs. C. got back some con-
trol over her movements, but at a certain point the
gain ceased, and we made no further progress, nor
did this surprise me. Hysterical paraplegia is, as I
have said, more hard to cure than any other hys-
terical trouble except, perhaps, multiple contractures,

22 DISEASES OF THE NEEVOUS SYSTEM.

and I felt that I had done well to win what I had
won.

About six months later this lady died after a brief
illness, which seemed to me more like a sudden and
complete palsy of the pneumogastric nerves than
anything else. 'No examination post mortem w^as
allowed. I have seen three deaths in hysteria; all
were abrupt, and two were due to acute congestion
of the kidneys.

The following case resulted more happily : The
patient, a woman get. 18 years, had been in good
health. Her paraplegia w^as caused by seeing her
father seriously injured by a fall from a horse. She
became feeble, ceased to eat sufficiently, and in a
week was unable to lift hand or foot. She was
brought to me six months later, and was then a rosy
girl of eighteen, not wasted, but presenting a singular
flabbiness of the muscular masses. The loss of power
in the legs and feet was so complete that, except in
the left foot, no motion could be seen. The hands
were so feeble as to be useless, although all the
fingers could be moved. Even the neck was too
weak to sustain the head. I had never seen the loss
of power in hysteria so complete. That of sensation
was not less so. The face was on both sides defective
in power to feel pain or touch, or change of tem-
perature, yet smell, taste, and hearing were as in
health. I expected to observe some notable func-
tional disturbance in the eyes, and therefore asked
Dr. Wm. Thomson to see her. The most elaborate
examination by this expert ophthalmologist failed to
show the existence of even the slightest defect of

PARALYSES OF HYSTERIA. 23

color-sense, or, in fact, anything except hyperme-
tropic astigmatism. Below the face there was no
ability to feel pain. The sense of touch was lessened
in acuteness, but not lost. The power to localize an
impression was impaired, and the sense of tempera-
tures lost. I should have said that beneath the skin
there was some feeling. On applying to the nipple
the bare metal poles of the secondary current of an
induction coil — a severe test — no signal of pain ap-
peared ; but, when two needles were carried through
the skin, and a strong current passed between them,
some pain was felt. Over the dorsal and cervical
spine — that is, from the third cervical to the tenth
dorsal spine — was a space about an inch wide in
which pin-pricks could be readily felt. Elsewhere the
needles used caused no more expression of pain than
if the woman's flesh had been a pincushion, and no
bleeding followed their use. As there w^as constant
regurgitation of strongly acidulated food after each
of the large meals she took, she was placed on the
exclusive use of milk containing two grains of bi-
carbonate of soda to the ounce. This, with massage
and electricity, and such training as I shall describe
at another place, triumphed after two months, and
she became able to eat, sleep, and walk, much as
others do. l^evertheless, the analgesia remained
nearly the same in the legs as at first, although it
disappeared above the waist almost entirely. The
sense of touch was not more improved than that of
pain, and this was as stated when she had become
well enough to walk two miles. She seems uncon-
scious of this continued defect, and my previous

24 DISEASES OF THE NERVOUS SYSTEM.

experience teaches me to hope that by degrees the
analgesia will disappear. In fact, the most useful
lesson we can draw from this and other like cases is
the fact that full volitional control may return while
the sense of touch or of pain remains greatly im-
paired. Once set the patient usefully afoot, and we
shall do well to cease to call attention to the con-
tinuance of the sensory failure. Secure to such cases
a quiet, unemotional life, and with the renewal of
healthy nutritive functions, the sensory failures will
in turn cease to exist.^

Of that more common type, the palsies of one side
of the body, you have seen a number. In this
country, at least, they are more frequent than the
paraplegias; less hard to cure, but quite lasting
enough to make you cautious as to what you predict
about their future. Where they occur in the feeble
and thin-blooded, who have by degrees grown emo-
tional, tearful, and weak of will, you may have more
hope of helping them than if they are met with in
robust people of non -emotional type, in whom the
usual emotional elements which go to build up this
temper of mind are wanting, or are small in amount.
The former offer through the relief of their nutritive
defects chances of obvious nature ; the latter are apt
to be bright or even able women, who enlist their
mental forces in behalf of their symptoms, and treat
the hated charge of being hysterical with utter
scorn.^

^ Six months after the above notes were written, I learn that the
patient whose case I have described above is perfectly well.

^ I ought, perhaps, to add that these women are usually mobile
and excitable by nature, prone to laughter more than tears, so that

PAEALYSES OF HYSTEKIA. 25

I cannot leave this subject of hemipalsies of hys-
teria without a few words as to the ordinary type of
this disorder. I shall, therefore, sketch for you
somewhat briefly the chief symptoms of hemiplegia
of hysterical origin.

This disease may come on slowly, and during the
varied course of a case of hysteria, or it may arise
abruptly — in an instant, even — in women known or
not suspected to be hysterical, owing to some pro-
found emotion or to an accident, such as a fall or a
wound. It is often of such insidious development
that its presence, when mild, is a thing rather to be
found by looking for it than of such a nature as to
be forced upon the attention of the observer. It is
excessively rare to see it as complete as we see a
hemiplegia of organic origin. J^early always — I
might venture to say always — it is associated with
some loss or disturbance of sensation. More often
this latter symptom is the dominant one, and the
lack of power merely amounts to a paresis or incom-
plete palsy.

Unlike the hemipalsy of cerebral and organic
cause, hysterical half-palsies involve more or less all
of one side of the body, excepting the face ; but in a
few rare cases the neck is distinctly affected, while
usually when the case is incomplete, it is the leg
which suffers most, both as to sensation and motion.

Apart from the fact that the face escapes, there
are other symptoms which differentiate these losses

it is hardly exact to say they are not emotional. Their form of too
ready emotional disturbance lies merely in an unusual direction for
the victims of hysteria.

3

26 DISEASES OF THE NERVOUS SYSTEM.

of power from those which are due to clots or emboli,
and a knowledge of which enables us to diagnosticate
the case with sufficient ease, as arising from hysteria.
As to locality, in Briquet's cases there were 70 on
the left to 20 on the right; in my own note-books, I
find the pi'oportion as 4 left to 1 right. The amount
of loss of power is often quite definite, but in other
cases it varies in degree, and from day to day, within
wider ranges than we see in palsies of organic birth.

It is exceedingly rare to see unilateral loss of
power in hysteria without distinct defects of feeling.

Sensation is disturbed, lessened, or lost either
throughout the one-half of the body or in varying
amounts over this space, and in the face, as a rule,
less than elsewhere. In rare cases, the sensibility
improves very near the middle line of the body. In
some instances no feeling exists; more often sense
of touch and power to localize sensations remains
with profound analgesia, and often also with lack of
power to tell heat from cold. In bad cases, espe-
cially if very feeble, the vision is subject to blurring,
or the eye on the affected side undergoes the curi-
ous loss of color-sense described by Galezowsky;
although in the milder cases, and in some grave
ones, this is assuredly not a constant symptom.
Deafness is much more rare, but has been seen
twice within a year in this clinic by Dr. Sinkler.

Charcot and Dr. Buzzard both state that the patel-
lar tendon reflex is exaggerated on the side of the
palsy, and the latter that the ankle clonus may at
times be met with. In the last three cases I have
seen of hysterical hemipalsy the patellar tendon reflex

PARALYSES OF HYSTERIA. 27

was increased on the affected side. In two others
it was notably lessened, as was the case in the girl
present at my last clinic, in whom it was only possible
to be sure that this symptom existed at all by grasp-
ing the muscles with one hand while the blow was
struck. In another case the flexors responded and
not the extensors ; and in yet another, with an exag-
gerated reflex, there was also a sharp contraction of
the adductors on both sides.

In a case now under my care there is slight con-
tracture of the calf muscles, and the heel is thus
drawn up. The attempt to evolve ankle clonus is
successful, but in a few seconds the extensor muscles
of the thigh jerk or twitch, and next the foot of the
sound side exhibits a beautiful example of ankle
clonus.

A good deal has been said as to ovarian tender-
ness in hysterical hemianeesthesia and in the yet
graver hysteric states. I put less stress on it than
is done by the school of Salpetriere. Often in hemi-
palsies of the kind we are now discussing there is
tenderness over a region which has by a sort of un-
questioning agreement been called ovarian, and which
begins at the groin, and is of variable extent. Some-
times there is no such sensitiveness, or else possibly
it extends above the navel, or it is felt only on deep
pressure, and in another case only upon pinching of
the skin. Then again, it may exist when one or
both ovaries are gone ; so that while we must admit
this sesthogenetic region as common in hysteria, we
must not too readily feel sure that its sensitiveness
is related directly to the little ovary beneath it.

28 DISEASES OF THE NERVOUS SYSTEM.

It has been shown of late that defects of the spe-
cial senses, once looked upon as peculiar to hysterical
hemiplegia, are to be met with also in palsies of
organic cause. I have elsewhere in this volume
spoken of ischsemia of the skin as being found
in other than hysteric analgesia. Within a few
months^ I have called attention to yet another resem-
blance between palsies of organic and of functional
birth; and have shown that in hysterical hemiplegia
we may meet with unilateral swelling analogous to
that seen in like palsies due to clots or emboli. The
oedema of organic brain disease w^hen present at
all is pretty constant ; that of hysteria varies enor-
mously, and is influenced by menstruation, exercise,
and emotional disturbances. It may be slight, or
may surpass by far any like disorder to be met with
in hemiplegia due to clot or embolus. There is also
something peculiar about the swelling. In places it
is clearly oedematous ; but in others no pit can be
made by pressure, or else the most prolonged pres-
sure is needed to produce this sign of oedema.

In the early stages of hysterical palsies the elec-
trical reactions are normal; but after a time changes
occur in a certain proportion of cases. These are
rarely such as indicate those degenerative changes
which force upon us the inference that the spinal
cord has undergone some destructive change. More
commonly long-contracted limbs, suflfering from the
atrophy of disuse, present merely a relative lessening
in response to maximal electrical excitations. Some-

^ Am. JoLirn. Med. Sci., July, 1884. Unilateral Swelling of
Hysterical Hemiplegia,

PAEALYSES OF HYSTERIA. 29

times we meet with eccentric phenomena which
demand further study. Thus, as is well known, it
is common to find the healthy response of muscles
to electricity delayed a little, or to see it increase
after the current has been used a few moments.
I^ow, in some hysterical cases, the only peculiarity
is an enormous increase in the length of this period.
I saw this well illustrated some time ago in a chronic
case of horrible rhythmic spasms of the arms, with
palsy of sense and motion in the legs. Dr. Yarrow,
the attending physician, studied with me the electric
state, which was curious. When with slow or rapid
breaking of circuit (induced currents) we tested the
leg muscles, the currents, although unbearable by
us, caused no motion until the}^ had been steadily
applied for from two to three minutes to any one
muscle.

There are, therefore, numerous points of likeness
between palsies of organic cause and those due to
hysteria. ]^evertheless, the differential diagnosis is
rarely difi&cult, and I may add that while I see many
mistakes made, owing to confounding hysteric para-
plegias with those of organic cause, I rarely see such
confusion as regards hysteric hemiplegia.

The following case, now in the Infirmary, may
serve as a fair type of this form of paralysis : Miss L.,
a fine, large, ruddy woman of 26 years of age, owes
her hemipalsy to the shock of a fall from affluence
to the need to support herself by giving lessons in
music. Then a succession of deaths fell upon her
household; and at last, one day, while engaged in
teaching, she fell asleep, as it were, abruptly, at about

3*

30 DISEASES OF THE NERVOUS SYSTEM.

9 A. M. She was aroused enough to be taken to bed,
and there remained thirteen hours, in what seemed
to be profound slumber. After this unusual trouble
she grew more and more hysterical, and at last came
under my care. Her organs are, in general, healthy;
but she has this curious peculiarity, of which she
seems quite unaware. The pulse varies from 80 to
95; but the respiration, without seeming to be hur-
ried or distressed, is never less than 40, and is often
60 to the minute.

She has considerable loss of power, with incom-
plete analgesia, defect of thermal sense, and preserva-
tion of touch. The face is scarcely affected at all,
and the senses of sight, smell, and taste are intact.
There is no ovarian tenderness on either side, and the
analgesia varies daily, almost hourly, as to extent,
place, and amount. A mustard plaster or blister, or,
more remarkably, freezing by rhigolene, will often
restore feeling over a large space for a few hours or
for days; but invariably the next menstrual flow un-
does whatever good may have been done. I tried the
'' metal cure" in this, as I have tried it over and over
in other and worse cases ; but, although from it, or
from glass, cork, wood, or what not, I have obtained
many times a slight local change in feeling, I have
never seen this complete, and have never once wit-
nessed the phenomenon of transfer of the analgesia
or ansesthesia to the opposite side — a phenomenon
which seems to be undeniably frequent in the hands
of as admirable an observer as Charcot. I ought to
add that my colleague, Dr. Sinkler, has not been in

PARALYSES OF HYSTERIA. 31

this matter more fortunate than I, although he has, I
believe, studied several cases from this point of view.
The patient I have mentioned has many other hys-
terical troubles, and, being quite rosy and stout, will
be a difficult case to deal with. It is interesting to
learn that until this girl came here neither she nor
her medical attendants were aware that she had any
loss of feeling.

The temperature of the left, the affected leg, is
normal, or the same as the other, and pin-pricks fail
to bleed at any part of the limb where there is
lessened feeling. The tendon reflex of the patella is
remarkably exaggerated on the palsied side, but
there is no ankle clonus. Under use of good diet
and tonics this girl is gaining color and weight,
while by a succession of irritants, chiefly the wire-
brush and induction currents, the sensation has been
more and more successfully restored, so that the last
menstrual flow, which commonly leaves her much
w^orse, has been less disastrous than usual.

I shall not trouble you further with details of this
the most common type of hysteric hemiplegia, but
pass on to one of the forms not well described as yet,
and which I shall, in advance, venture to call double
hemiplegia. This, as we shall presently see, is not
merely another name for paraplegia.

Miss B., a sturdy, handsome girl, set. 16 years,
had a series of ills, one on another, from time to
time. The first sign of trouble was twitches of the
eyelids, and tears on reading ; then there was a pause
of two years. The next disturbance was a noisy and
obstinate hiccup, during which both iliac fosspe be-

32 DISEASES OF THE NERVOUS SYSTEM.

came tender, and a single hypodermic use of morphia
was followed by convulsions. Il^ext came hysteric
loss of desire for food, nausea, pains in the left arm
and leg, and spasm of the vessels in the left leg, so
that it became white and cold. Up to this time she
still walked out; but in the summer of 1878 the use
of galvanism is said to have been followed by sick
stomach and loss of power to stand. In the autumn
she got rid of immense masses of hard feces, when
all the symptoms improved for a time. The next
winter was passed in bed, vomiting a good deal;
eating little; the bowels very hard to move; the
urine passed every hour. About this time, also, she
began to shun light, and came at last to living, with
covered eyes, in a darkened room. When I saw
this young lady I was struck with the thorough type
of the emotional hysteric person she showed ; nor
from the usual weak will to the usual love of sym-
pathy was there any tint wanting to the picture. I
watched her for a few daj^s without ordering treat-
ment, until I learned all I could of herself, her his-
tory, her home-life, her pursuits, her ambitions, and
her mental powers. Then a talk with a watchful
nurse helped me further, and I saw clearly that I
had to do not with a clever woman who may be won
over, and who is flattered by the tribute paid to her
mind when you insist that to cure her she must be
made to understand and agree with you, but with a
child who, to be made well, had to be calmly and
firml}' ruled, and held day b}^ day to rigid account.
She was at once shut up, with a good nurse, and kept
at rest in bed, not being allowed to use her hands

PARALYSES OF HYSTERIA. 33

even to feed herself. As she had been able to knit
and sew, and be read to, and to receive many visits,
the sense of the irksomeness of the treatment soon
made her eager to do anything I wished. Then
began a system of bribes. She was told that if she
could learn to bear the light she would be able to be
read to, but that the nurse could not be allowed to
strain her eyes. It would have been easy to open
the windows and say you must bear the light, but if
she herself gained this point of vantage, it would
have the great value of being a self-conquest. In a
few days I found the sunlight bright in her room.
Then she was asked to overcome the habit of regur-
gitating her food. One or two scoldings, some show
of disgust, and the promise that she should soon feed
herself if she obeyed my wishes, helped us through
with this. There were relapses; but as I found she
hated milk I felt forced to put her back on the milk
diet we began with whenever she threw up a meal,
so that before long we heard no more of the vomit-
ing; meanwhile the steady feeding and the use of
massage, and local muscle treatment by electricity,
began to show in a gain of flesh and color and firm-
ness of muscle. She was now very weary of this
unending quiet, and the time for education of the
motor powers seemed to have come. Her loss of
motion on the left side was very marked, and there
was complete want of power to feel pain or to tell
heat from cold; yet I could not make out any loss
of vision or of color-sense. The touch was not per-
fect, but she knew fairly well where she was touched,
although she could not be tickled.

34 DISEASES OF THE NERVOUS SYSTEM.

As regards the pain-sense, there was one very
curious point to which I have already alluded. As
the needle came within an inch or two of the middle
line of the body, both at the back and front, it was
felt, and the better felt the nearer it came to this
line ; nor do I recall having met with this fact in
any case of palsy from organic cause. The right
side of the body was palsied in a less degree, and
only as to motion, the leg far more than the arm.
The same was the case on the left side as regards all
the forms in which the functions were deficient.
]^ow as this case grew better the right side became
entirely well first, leaving the left hemiplegia as
before, so that I have reason to speak of the whole
loss as being due to a double hemiplegia. In other
cases I have seen a general loss of sense and motion,
and observed entire relief on the right side, leaving
only a hemiplegia of the left.

My patient had some wasting of the left leg, and
less good electro-muscular reaction on the left, but
no pain on that side from any form of current. The
tendon reflex below^ the knee-pan was good on the
right, and also on the left ; but, what was new to me,
the jerk was sometimes due to the extensors, and
sometimes due to the flexors, the extensors in the
latter case not seeming to move at all. Here was
another of the oddities of this most strange disorder.

As is usual, she moved her limbs best while in
bed ; and showed, when I came to let her sit up, or
stand, the loss of balancing power which is seen in
all grave hysteric palsies, and is, indeed, almost a
sure sign of the parentage of the disease.

PARALYSES OF HYSTERIA. 35

I have often asked you to note another point which
this case showed very welL You ask the patient to
raise the leg; it is lifted an inch. You insist on
effort; it is lifted higher; or, if a great effort be
made, the motion consists of a series of lifts and
pauses.

The reliefs of distinct hystero-palsies are said to
be often abrupt. Under emotion or return of the
menstrual flow, or on an order from some one, the
patient gets well. I must say that in hystero-hemi-
plegia and paraplegia, with loss of feeling, I have
not been so happy as to see these delightful cures.
In hysteria with mere paresis, in the palsies from
belief, or from a ruling idea, I have seen such results
many times. Neither do I believe that all hysteria
is after a time within control of the sick person; nor
that she can in all instances run away in case of a
fire, according to a popular belief In fact, I have
now in my care a lady who was so tested by chance,
and who utterly failed to do more than fall down in
her effort to escape from a house on fire.

In fact, profound emotions may work either way
for good or for ill, and no human sagacity will suf-
fice to enable us to predict results. The evil is quite
as likely to be prominent as the good, and at all
events you may rest assured that emotions are some-
w^hat unmanageable and unreliable as therapeutic
agents.

I have felt the need to say this, even if too briefly,
because I must add that the cures of these cases are
to be made by a slow, steady, hopeful training of the
will powers through every-day effort, which needs

36 DISEASES OF THE NERVOUS SYSTEM.

some caution not to err in the way of excess. A
little nervousness is a bad sign, and it is well each
day to attempt a very little — no matter how little if
only we succeed, and can make the patient see it. I
shall in another place be more precise as to the means
used. Enough to say of this case that it went on
slowly gaining ground, and was under my care a
year before the patient could walk well enough on
crutches to go home with a cheerful future. It was
not a brilliant case, and it taxed nurse and doctor to
the uttermost — a case urged and scolded, and teased
and bribed, and decoyed along the road to health;
but this is what it means to treat hysteria. There is
no short cut; no royal road.

Let us take another case. It was as much like the
last as it could well be. The patient, Miss C. P., set.
18 years, the child of wealthy parents, came to me
last year from Indiana. The motor losses were very
remarkable, and, as in the last case, it was the left
side which suffered most. She was unable to lift
the left leg, or flex or extend the foot, so that below
the knee there was motion in the toes alone. The
left arm preserved all movements, but all alike were
feeble. The right side was more symmetrically dis-
ordered, so that almost every muscle of the leg and
arm was partially paralyzed. Sensation was lost for
pain on the left side, save as to the belly and breast,
where it seemed to be good, while in the face and
neck it was lessened. Sense of temperature was
more absolutely lost over the whole side than is com-
mon; and touch, not quite lost anywhere, was dis-
turbed or lessened in irregular spaces. On the right

PAKALYSES OF HYSTERIA. 37

side sense of pain was lessened in the arm and lost
in the leg, while touch and the thernaal sense were
well preserved. There was one matter in which this
case differed from the last one, and this changed my
whole manner of dealing with the malady. My new
patient was a clear-headed, well-educated girl, who
had once had a vigorous will. She was described to
me as unselfish, thoughtful, and intelligent, and as a
woman only brought down to a state of hysteria by
long illness and the want of helpful advice at the
right moment. She was emotional and ashamed of
her tears, and honestly hated the whole matter of
sickness. You will see such hysterical women. You
will see others whose minds are like the back of a
piece of needle-work with a bafi[ling absence of pat-
tern— women with a low, whining, bleating voice
that is by itself a tell-tale of the kind of will-less
ataxia which seems to cripple the mind no less than
the body. These are the hard cases to relieve. But
to return to my more favorable case. I tried to
make her see how m.uch the defects of body have
to do with those of mind, and therefore the need to
begin by building up the body anew. When, after
a time, the limbs began to round, and color to come
back to her pallid cheek, I set her to thinking how
far the early troubles might have been within her
control. I assured her that, although she could not
now overcome at once the results due to habitual
failure of self-control, repeated efforts would surely
end in success. She was told that it was like the
case of a bad temper, easy to hold in check at first,
but if long unheld at last uncontrollable. It is not

4

38 DISEASES OF THE NERVOUS SYSTEM.

hard to open this point of view to a clever woman.
You urge this idea from day to day; you ask her to
try your way. She says she has done so, and then
3^ou point out that with ill-health success was out of
the question, while with rising health it might be
easy. At last you get her to promise to fight every
desire to cry, or twitch, or grow excited.

Above all, you teach her the priceless lesson for a
woman of the value of moods, of the ease with which
she can get herself into a state of dangerous tension,
of the necessity of learning, not how to bear a thing,
but how to approach the idea of bearing it in a state
of calm. It is a long sermon, but I can only give
these few pregnant texts. It is always apt to win
with a woman of intelligence, and the fools are to be
dealt with by other moral drugs than these, or the
honest pill must be gilded with timely flattery or
such better motives as ma}^ help it to find the
woman's conscience, if that is to be stirred at all.

By and by, as one symptom after another gave
way before her eftbrts, she became more and more
sure that I must be right as to all ; and I have seen
few cases gain ground with equal speed. I^everthe-
less a whole year was needed to make her well able
to take up afresh her full round of social and house-
hold duties. In fact, even with the best of self-help
from the patient, the cure of any one of these cases
is a long and arduous course of education.

HYSTERICAL MOTOR ATAXIA. 39

LECTURE II.

HYSTEKICAL MOTOK ATAXIA— HYSTEKICAL
PAEESIS.

The form of disorder to which I shall next direct
your attention in connection with hysteria is the
motor ataxia of this disease. It is necessary here to
be extremely precise, because, as you will see if you
read Briquet's admirable study of hysteria, he also
describes a form of hysterical motor ataxia.

Ataxia, as you well know, means merely disorder
or irregularity, and when therefore we speak of loco-
motor ataxia we mean only disordered movement,
and not of necessity enfeebled movement. The cause
of the disorder or incoordination thus introduced into
motor functions may vary.

In hysteria, so far as I know, there are two forms
of motor ataxia independent of those associated with
vertigo. That described by Briquet and Lasegue
seems to depend upon a loss of sensation in both
skin and muscles. In Lasegue's case the girl was
only able, the eyes being closed, to move the limbs
which were still sensible, but was totally unable to
move the anaesthetized parts, or to know where they
were when moved by another person. While see-
ing, she could walk readily and even without looking

40 DISEASES OF THE NERVOUS SYSTEM.

at her feet.^ In other and similar cases there is
merely a lack of coordination in complex motor
acts.

There is, however, another and a very interesting
form of hysterical motor ataxia, as yet undescribed,
which is, I fancy, rather rare in its most perfect type,
and which may without due care be taken, as was
posterior sclerosis of the cord long taken, for some
kind of paralysis.

The trouble I am about to speak of I find to be
in some of its degrees very common in hysteria — to
coexist with many hysteric palsies or paretic states,
and sometimes, though rarely, to be the prominent
malady, with almost no loss of voluntary power.

The hysterical ataxic patient of this class, and I
shall consider first the nearly pure case, has full feel-
ing, or may have it, and is quite well able to use the
limbs more or less freely while lying down. When
she begins to sit up or kneel or stand, the lack of
coordinate muscular movements becomes at once
visible.

Instantly the patient begins to fall to one side, a
voluntary effort to redress the disturbed balance
results in' a partial fall to the other side, or back or
forward, as may chance. The patient seeyns to be
unable to judge of the extent to which the balance is
lost, and also to determine or evolve the amount of

1 There may be in this something of habit. In the few cases of
spinal locomotor ataxia which I have seen in women I have been
struck with the way in which, as their garments habitually hide
the feet, they managed to dispense with the guiding sight of these
parts.

HYSTERICAL MOTOR ATAXIA. 41

power needed to overcome the defect. The abrupt-
ness of these efforts at redressing the loss of equi-
librium appears to show an absence of defect of the
usual antagonistic activity of opponent muscles. I
am inclined to suggest as a reasonable theory that
perhaps a large share of this difficulty may be due to
a slowness in volitional acts by reason of which the
mandate reaches the muscle loo late to be of ready
service. This is by no means unlikely, for in some
hystero-palsies I have measured and proved the re-
tardation of nerve-conduction. Slowness in learning
the need to move a muscle and slowness in moving
it would give rise to just such incoordinate action as
these cases exhibit. The lack of orderly movement
is chiefly in the neck and trunk, and is made worse,
like all disorder of motion, by excluding the guiding
influence of vision.

This very interesting form of incoordination in
muscular acts is limited for the most part to the more
complex movements. It is seen little or least in
single limb motions, better in sitting or kneeling,
better still in standing, and best of all in walking.
It is not due to weakness because it exists in cases
strong enough to sit, stand, and walk firmly, if only
power were needed to the efficient accomplishment of
these acts. Also, while you may find it with general
or local lack of surface feeling, it is not due to this,
because anaesthesia of the skin alone is, in the hys-
terical at least, incompetent to cause ataxia of motion.
In the confusion and odd grouping of symptoms in
hysteria, the trouble I have described is apt to be
overlooked or attributed to coincident conditions.

4*

42 DISEASES OF THE NERVOUS SYSTEM.

It is, therefore, fortunate to find now and then cases
in which this form of motor disorder occurs almost
alone, so that we have a chance of studying it without
being embarrassed by other symptoms.

I believe that this ataxic state is common in grave
hysteria, and is to be found often enough in milder
cases. I think also that some of the cases which are
attributed too promptly to muscular anaesthesia will
be found to be free from that defect, and to be due
to other causes than those to which Briquet has at-
tributed them. Perhaps it may be that conscience
of locality will prove a differentiating test, since it
is said to be lost in the hysterical ataxia of Briquet,
and is certainly not always lost in the form I have
here delineated.

I do not think one could readily confound this
ataxia of movement with anything else, unless it be
with one of the rarest of the forms of hysterical
spasm. The following case is an apt illustration of
this latter disease which might, perhaps, be well de-
scribed as alternating spasms, the action of the flexors
calling the extensors instantly into movement, and
these in turn summoning the flexors into like activity.
These semi-spasmodic motions were the more curious
in the last case I saw, because of the general and pro-
found paresis which made every volitional effort ex-
cessively difficult. I may add that there was also a
contraction of the right leg and a left hemi-ansesthesia
with fair conscience of the place of a touch.

The patient, when seated and held up, or even
when the head alone was unsustained, showed the
following symptoms : The head or body was pulled

HYSTERICAL MOTOR ATAXIA. 43

to one side. At the limit of this motion, or before
that was reached, it was violently jerked over by the
opponent muscles, as if their stretching were the sig-
nal for an explosive act of power. At once, or in a
moment, the other muscles acted in like fashion, and
so the head or trunk was thrown about in a strange
and disorderly manner so long as the patient remained
upright. The same type of movement extended to
the legs and arms. These acts were certainly of
volitional birth, but they were, so to speak, convul-
sive renderings of natural acts, and were sometimes
very violent.

I may add that, notwithstanding the complexity
of symptoms, with such a loss of memory as necessi-
tated an entire reeducation, this girl became entirely
well.

In place of giving you types of motor ataxia with
palsy I shall prefer to choose one now in my care,
and which has the least share of palsy for the largest
share of incoordination of the muscles.

Miss B., set. 20, Kentucky, of healthy, living
parents, in August, 1876, while going home from
the Centennial Exhibition, caught a slight cold, out
of which came complete loss of voice for seventeen
months. In its return it came and went abruptly,
and was well to-day and gone to-morrow. In Sep-
tember, 1871, at the Hot Springs, Arkansas, after a
good deal of worry, she is said to have had headache
and dizziness, after which of a sudden she lost speech,
and became unconscious, with her jaws firmly locked.
The legs and arms were seized with spasms, and
when they became better had nearly lost touch-sense,

44 DISEASES OF THE NERVOUS SYSTEM.

and did not feel pin-pricks. This attack ended in
weakness and fever, with cold feet and loss of power
to swallow even saliva. After three weeks she re-
gained speech, and then again relapsed. She was
said to have had a typhoid fever, which does not
seem likely.

About the fifth week she was found to have lost
power in the legs. The loss is described as having
been nearly entire; but by March, 1879, she had re-
gained a good deal of motion. Since then she has
been at a standstill.

In October, I saw Miss B. in bed, a dark-skinned,
rosy-looking girl, without the least turn to tears or
undue emotion. I should only have said that her
manner was quick and excitable. She certainly had
none of the usual furtive look, and small deceitful-
nesses of some hysterical girls. E^either was there
any loss of tendon (patellar) reflex, and the senses of
pain, of touch, and of heat were perfect.

While in bed, Miss B. moved all her limbs some-
what slowly, but with a great deal of power; the
lift of the leg was done in jerks, as by distinct orders
of will, but she showed none of the tremor and
twitching of face and tearful look so common in
hysteric girls called on for an unusual effort. When
held up on her knees, she swayed to and fro, always
falling if not assisted. When somewhat later she
could stand up, the motor disorder showed still
better. From head to foot every muscle used to
preserve the upright posture gave Vs'slj momently,
and was braced again by distinct acts of will. The
rocking motion so caused was curious to see. A

HYSTERICAL MOTOR ATAXIA. 45

slight push was sure to upset her, as if she was un-
able to provide in time enough of power to resist
the shock and restore the disturbed balance. If I
warned her of the coming shock, she did far better.
The touch of a hand greatly aided her, and the
closing of her eyes made things worse. I^or did
Miss B., when standing, appear to have the least
idea of her balance being in danger until the sway
of her figure became extreme, when she caught her-
self up, and with an effort regained her erect position
only to fall to the other side. There seemed to be a
lack of appreciation of the failing balance, and a
slowness in redressing it when lost or in peril. When
added to this we have complete loss of feeling —
when skin, bone, joint, and muscle share alike in
this respect — we have, of course, a still more com-
plete and a different form of want of power to pre-
serve the upright posture ; but this is said to be the
character of the trouble spoken of by Briquet and
others, and I wished to make it clear that there were
causes of motor ataxy which did not of need involve
any lack of tactile sense.

In Miss B.'s case, little was needed beyond train-
ing the weak and inapt muscles, because she ate and
digested well, slept soundly, and was free from pain.

My first step was to point out to her that, after she
had made an effort which seemed extreme, another
forth-putting of will would add to the previous result.
This seems a simple thing to make clear ; but, if you
can convince your patient of the fact, it is of great
service, because then you go on to point out further
that, perliaps, by a series of trained and aided efforts,

46 DISEASES OF THE NERVOUS SYSTEM.

there may be won, bit by bit, a full power of motion.
To lodge this idea in a woman's mind is at once to
widen the horizon of hope. How much you gain by
it depends a little on whether your patient is clever
and wants to get well, or is silly and prefers the role
of hysteria; but, after all, the whole mode of treat-
ment rests on a study of character, or of character
and hysteria, and a moral diagnosis is the first step
to take.

With Miss B., at a standstill for months — bright,
clever, longing for active life — the idea was as a
wholesome ferment. The nurse now began to train
her while in bed to move the legs, one at a time,
very slowly, but in larger and larger movements,
with intervals between of a minute or more.

An order is given to lift the leg ; if it be too weak,
a finger beneath the ankle aids it, but no attempt
must be let to fail utterly; as she gets on, the orders
are to be obeyed more quickly. It is easy to sketch
out for one's self what such a system should be in its
details. After it has gone far enough, the patient is
seated in bed with some support to her spine, and is
trained to move the head freely. When, in Miss B.'s
case, she was put on the edge of the bed seated, the
motor ataxia began to show, so that it took some
time to overcome this trouble. The next step used
with me to be a lesson in walking, but of late I find
it better to teach the girl to creep, which is an easy
and natural mode of training for the walk. The
patient has pads tied over her knees, and, lying flat
on her face on the floor, without skirts, has around
her a folded sheet. At an order, she tries to rise,

HYSTERICAL MOTOR ATAXIA. 47

helped by the lift of the sheet-belt held b}^ the nurse.
When she is able to do this, and can gather her legs
and arms so as to make herself a quadruped, she is
taught to balance herself, every effort being assisted,
when needing help, by the nurse standing above her.
The progress to creeping is easy; then comes the
lesson of kneeling and pushing a chair ; and, last,
that of standing in a corner or by a chair. You see
that, following nature's lessons with docile mind, we
have treated the woman as nature treats an infant.
For aid in walking we have three devices : the ex-
pensive wheel crutch, which can be easily imitated
by a clever carpenter, being merely a framework
with rollers so arranged that it includes crutch sup-
ports. E'ext, if need be, I use a device which may
be common, for all I know, but which I have not
seen elsewhere. It is a pair of crutches with a stout
half-hoop of metal between and in front of the two.
This gives a solid support, and, in ataxic cases, is
very useful as giving a sense of security, and, there-
fore, of confidence. This crutch-frame is soon re-
placed by a pair of supports, the bases of which are
about seven or eight inches long and two broad.
They may be made like the lower half of a crutch,
or have two columns of a support set in the base, or
may be a single cane with broad base ; the top in
any case should have a double curve so as to lie
easily in the line of the natual slope of the palm
when resting on such a support. A rubber footing
gives a little elasticity and a good hold on any form
of flooring. With such a broad base of support, it
is quite pleasant to find how soon the patient learns

48 DISEASES OF THE NERVOUS SYSTEM.

with its aid to balance herself. A third form of
support, which I devised two or three years ago, is
of use in hj^steric or in any form of hemiplegia. If
the left arm be too feeble to aid the left leg by
grasping a crutch, I resort to the following arrange-
ment. On the lame side a crutch, having above an
unusually deep hollow to receive the armpit, is
fastened to the arm by two straps or by a glove
riveted to the hand-piece of the crutch, so as that
the hand, once slipped into it, is pretty firmly held.
From the crutch a double metal bar curves forward
and towards the sound side, and ends in a handle
which is grasped by the sound hand and carried for-
ward by it. I have found these supports most useful
in many forms of weakness. In making them, or
having them made, pray remember that they should
be made light ; most crutches are too heavy.

With regard to Miss B., I may add that she got
well in two months, so as to walk unhelped anywhere,
and that she is now free from pain and nervousness.

Before leaving the subject of hysteric motor ataxy,
I wish to add yet a single illustrative case in order
to show that ataxy, connected with hemiplegia, may
affect a single limb. Such cases approach in char-
acter the choreoid troubles which accompany or
follow certain cases of hemiplegia from organic dis-
ease of the brain, and afford yet another of the
shadowy resemblances which link the various forms
of hysterical disorders to their analogues of more
definite parentage. Miss C, set. 30, grew up in
luxury and ease, subject to what she somewhat in-
definitely described as spells of prostration with

HYSTERICAL MOTOR ATAXIA. 49

nervousness. At the age of twenty, a sudden death
in her family caused a sharp convulsive attack, fol-
lowed by a brief period of insanity, lasting in all
three weeks. Three years later, her family fell into
almost absolute want, and she began to work hard
in the effort at self-support, and then gradually failed
in health, suffering at intervals from a variety of
hysterical symptoms. These resulted abruptly in
incomplete left hemi-ansesthesia, with great loss of
power in the leg, and lessened power in the hand
and arm.

With this report of her case, she came to me some
months ago. Except a very slight retro-flexion,
there was no uterine trouble. E^either ovary was
sensitive, but the spine in all its length, and the left
side of the chest and the upper part of the belly,
were very tender — more to touch than deep pressure.
All other organs were healthy.

The hemi-ansesthesia as to touch and pain was
notable in the parts below the waist, and was incom-
plete in irregular areas, which shifted daily. Pin-
pricks did not bleed in the leg.

The hand and arm had good sense of touch every-
where, but lessened pain-sense chiefly on the radial
aspect of the arm. The leg was almost motionless.
The arm and hand could be used with nearly natural
force, but were stricken with remarkable ataxy of
movement without the least sign of spasm. The
utmost concentration of will failed to direct the hand
so as to enable it to grasp or manipulate an object
once held. The limb would waver to and fro, and
at last descend on the object with an effort which

5

60 DISEASES OF THE NERVOUS SYSTEM.

usually carried the hand far to left or right. A
certain abrupt jerkiness characterized every motion,
and the failure of directive power was singularly
illustrated at the piano, where the one incoordinate
member contrasted with the unusually skilful touch
of the other. As so often happens in the post-
paralytic chorea of cerebral lesions, the palsy was
inversely as the ataxic difficulty, and consisted rather
in lack of persistent energy than in want of initiatory
power.

By slow degrees this ataxy of movement passed
away, and, w^iat was most curious, it lessened with
the increase in want of power, while this also has in
turn disappeared, leaving as yet some dyssesthesia,
but no notable want of strength.

There yet remains to us hysteric paresis. Among
the many disorders which hysteria affords, certain
ones come clearly out at times from the tangle of
named or nameless symptoms, and enable us to
speak of them under some distinct name. It is a
comfort, amidst so much that is confusing, to find
these groupings of symptoms ; and, in diseases of
vague boundaries like neurasthenia and hysteria, a
good deal of this useful sort of secondary classifica-
tion is possible.

The history of hysteria is sometimes one of years,
and in certain cases, either at the outset or after more
or less of the strange drama of this disease has been
played, the patient falls into a state of inertness of
mind and body, which I am forced, for lack of a
better name, to call hysteric paresis.

You might, I presume, feel free to give to these

HYSTEKICAL MOTOR ATAXIA. 51

cases another label than the one I have given. They
are, however, over and above all else, pareses —
examples of intense feebleness, free from any accom-
panying defect of sensation ; but it is paresis in hys-
terical women, and if you forget this fact, you may
be sure that you will have but little success in the
treatment.

This disorder may be seen in union with other
signs which are more or less clearly hysterical; but
sometimes we find it almost pure from these dis-
guises, as in the case of Miss L., from IsTew Jersey,
now in the Infirmary. A person of languid nature,
not strong in mind or body, she began some years
ago to be emotional, to have loss of appetite, weak-
ness, tender spine, vertex headaches, abdominal
tenderness, and rare convulsions. By and by she
took to bed, and with more and more complaint of
her back, and soon of soreness everywhere, ate less
and less, gave no care to her bowels, and at last be-
came feeble, sallow, wasted to the limit of wasting,
and content to lie still most of the time, using mind
and body as little as she could. From this state I
rescued her and made her well, and now she is here
again far worse than ever, unable to lift a limb or to
turn over. She is twenty-two years old, and has not
menstruated in six months. She is five feet five
inches, and may weigh about eighty-eight pounds.
Her skin is rough, dry, unpliant, yellowish, and
seems to be firmly glued to the bones and muscles
beneath it. Her morning temperature does not ex-
ceed 97.5° F. ; her heart beats 90 to 120, and is quick
and feeble. The other organs seem healthy, and the

52 DISEASES OF THE NERVOUS SYSTEM.

secretions normal. She cries at times, but not mucli.
Her face, marked with acne, is set, inert, wooden,
as if she could not smile. The lids droop, the mouth
hangs a little open, the voice is so feeble that it is
hard to know what she says. The spine is very
tender, and to touch it causes a gush of tears ; but
the left iliac fossa and the chest muscles are also
tender, and compression of any of these hyperses-
thetic spaces causes nausea and vertigo. Her dislike
to make any effort was great, but it was also clear
that the power to move was not lost. There w^as
not during movement the jerky action of hystero-
palsies, but an extreme and evident difficulty in
motion, and a sudden failure to prolong it; observe
also that sensation was unimpaired.

I was very much struck in this case with the ease
with which these patients become feverish. The
least overexertion was competent to cause a distinct
rise in temperature and pulse ; but, for some reason
not yet clear to me, these changes required some
hours to produce them.

All the battery of toning influences was turned on
this woman, and she is now gaining ground apace.
She is fed often and in small amount, had for a time
rectal feeding also — and the mechanical tonics, mas-
sage and electricity. As usual in all such cases, we
wait until the flesh is coming back, the color bright-
ens, and the muscles grow firmer under our mechan-
ical stimulations, before we call upon her to exert
herself. Then, in this order, with passive motion —
motion aided hy a nurse, motion resisted by a nurse,
active motion, unhelped — we shall train her back to

HYSTERICAL MOTOR ATAXIA. 53

a state of health. We shall cure her surely, but
whether or not she will remain well I cannot say.
It will depend on what kind of influences surround
her, on what she is when well.

I have given here a short sketch of a state of
paresis, in which with some anaemia or without a
very marked condition of lack of blood all the func-
tions are enfeebled, and this is most notable in those
which involve muscular exertion of any kind. If
there be also any pain, such as that of spinal irrita-
tion made worse by motion, the patient is even more
apt to be sluggish, and is not slow to avail herself of
this and of every excuse to keep as quiet as possible.
The real and singular want of power, as measured by
the dynamometer, the difficulty in beginning as well
as in continuing a motion, seems to set this apart
from cases of mere neurasthenia, while the general
wasting and appearance of malnutrition serve yet
more deeply to mark the distinction. The disorder
I have described so briefly is one of those which adds
many recruits to that large class which some one has
called ^' bed cases," and which are above all things
distinguished by their desire to remain at rest.

I shall elsewhere give in sufficient detail what I
over and over allude to in these lectures — my views
as to how best to treat those difficult combinations
of hysteria with defective nutrition which are often
too much for the best of us, and to those pages, and
to what I have written previously in other places, I
must now refer you. I have some belief in the occa-
sional value of induction-currents in hystero-palsies,
but, as to the direct good to be had out of the drugs

5*

54 DISEASES OF THE NERVOUS SYSTEM.

on which men once relied in the treatment of this
disease, I have said nothing, because, except to con-
demn, I had nothing to say, and because I believe
that the numberless remedies for hysteria to be found
in the books will be swept by another generation into
the limbo provided for drugs with decayed reputa-
tions ; but in thus expressing myself I do not mean
to say that no drugs have an indirect value. What
you have to do is to rectify with care positive uterine
troubles, to treat defects of nutrition, to relieve the
anaemia so apt to exist in hysteria, to see that every
function is well cared for, and last, not least, to learn
what need there is to alter the moral surroundings
of your patient, and then with kind and patient care,
and an unbending will, to bring about the changes
she may seem to require.

MIMICRY OF DISEASE. o5

LECTURE III.

MIMICKY OF DISEASE.

You will recall the fact that the case I show you
to-day is one of three which have presented them-
selves at this clinic within one week. Each of these
by chance illustrates a different form of disorder, and
each of the three is a distinct example of one of the
various groups of causes which evolve a simulation
of disease. The literature of this subject is widely
scattered, and consists chiefly of isolated cases to be
found in the journals. The best essays on the surgi-
cal aspect of simulated disorders are the admirable
lectures of Paget,^ Skey's^ little volume, and an able
paper by Dr. Shaffer,^ of New York, on hysterical dis-
ease of joints. Except Russell Reynolds's^ admirable
paper on diseases due to fixed ideas or emotions, I
know of no medical essay of much merit on this sub-
j ect. I regret that the able physician I have j ust named
has not further treated of these forms of disorder; no
one was better fitted to do so. It is, in truth, to be de-
sired that the whole subject should be handled afresh
by some as competent observer. It would be easy for

1 Paget, Sir J., Clinical Lectures and Essays.

2 Skey, E. C, Lectures on Hysteria.

3 The Hysterical Element in Orthopaedic Surgery.
* See Brit. Med. Journ., 1869, pp. 378 and 483.

66 DISEASES OF THE NERVOUS SYSTEM.

me to make up for you an interesting history of these
troubles from the experience of others, but I think
that I shall be more pleasantly instructive if I deal
only, or most largely, with cases coming within the
range of my own knowledge, and especially if I
make use of some of the curious self-analyses which
patients who have recovered have placed at my dis-
posal. Both for what they betray and what they
conceal these histories are valuable, and especially
so when they come from women of educated intel-
ligence.

The elements out of which these disorders arise
are deeply human, and exist in all of us in varying
amount, while many of the determining and con-
ditioning factors come from accidental, or, at least,
external agencies. As a rule, the means at work to
produce mimicked disease are in the books made to
seem too simple.

I have not time to do here as I might wish, and to
go into the full psychology of this subject, and must
content myself, therefore, with an outline which shall
mark out for you the chief causes which supply the
foundations for simulated diseases, and those which
build on this, and those w^hich strengthen and guard
the morbid structure.

First of all comes the hysterical state, fertile parent
of evil. However produced, it is a fruitful source of
mimicry of disease, in its every form, from the mild-
est of dreamed pains up to the most complete and
carefully devised frauds Its sensitiveness and mo-
bility, its timidity and emotionalness, its greed of
attention, of sympathy, and of power in all shapes,

MIMICKY OF DISEASE. 57

supply both motive and help, so that while we must
be careful not to see mimicry in every hysteric symp-
tom, we must, in people of this temperament, be more
than usually watchful for this form of trouble, and
at least reasonably suspicious of every peculiar or
unusual phenomenon.

What it is convenient to call the nervous tempera-
ment, or that state which may be acquired, and which
I like to describe as general nervousness, is a fertile
field for simulated maladies, because in it, as in hys-
teria, the qualities which we all possess are apt to
take on a morbid development, and to get out of the
limits of rational control.

Of the individual share taken by each of these
causes I shall by and by speak. Before, however, I
pass .on to lesser premises, I would like to digress in
order to say a few words in explanation of what I
mean hy general nervousness. You will find this
term used over and over in these lectures, and also
in the annual statement of diseases treated at the
Infirmary for diseases of the nervous system. I used
to try to classify these cases under other heads, but
came at last to see that there is a state which is best
labelled thus, and that after eliminating all the cases
which can be otherwise classed, a small residuum is
left to which no other name applies. Some of them
are more or less neurasthenic people, easily tired in
brain or body ; but others without this, or with this
peculiarity but slightly developed, are merely tremu-
lous, nervous folks, easily agitated, over-sensitive,
emotional, and timid. This state falls on man or
woman or child, and is not hysteria. It is with some

58 DISEASES OF THE NEEVOUS SYSTEM.

people a morbid birth-gift, with some an inheritance,
and in its worst shapes it is made or acquired by
misuse of alcohol or tobacco, or tea or coffee.
IsTaturallv you may think that such a state must be
slowly created, and usually it is; but also it is true
that a very permanent state of general nervousness
may be evolved by the accident of a moment, when
precedent conditions favor it. In a lecture on general
nervousness in the male, I mentioned examples of
this kind, and last week we saw at my clinic a case
in which a moment of intense terror, owing to the
fall of a house wall, caused in a healthy girl a state
of general nervousness, alike serious and lasting.
However acquired, the condition I have outlined
highly favors the mimicry of disease.

Another good growing ground for simulation is
in a mere lowering of the general tone of health
from ansemia, or any cause whatsoever. You know
that out of failing health comes, often enough, nerv-
ousness or hysteria, but even when these states do
not arise, mere lowering of the standard helps, in
many susceptible people, to awaken doubts, sus-
picions, and terrors, which need little hint or help
from without to enable the victim to construct a
morbid edifice of non-existent disease.

If, then, you should ask me whether for the
creation of mimicked disorders we need the aid of
lowered health, of hysteria, or of general nervous-
ness, I should answer that while such states are
usually the responsible parents, a small proportion
of examples arise in persons who, being in absolute
health, owe the troubles in question to their possess-

MIMICRY OF DISEASE. 59

ing some natural or inherited combination of physical
peculiarities, which becomes a competent mischief-
maker when aided by external accident. The people
who, from any cause, simulate disease are, I think,
apt to be naturally distinguished by certain peculiari-
ties. They are generally over-sensitive, pain hurts
them more than others, and is a more important
matter in life. Perhaps they really feel pain more,
and, at all events, they complain of it more. As a
rule, they are timid, fearful, and watchful, nursing
for evil, any chance word incautiously dropped, and,
therefore, prone to dwell on physicians' opinions, to
deduce exaggerated possibilities of trouble, and in
obedience to the least prediction of ill to consent or
hasten to take extreme precautions.

Then, again, you are aware that everyone has
some capacity for mentally influencing or disturbing
functions of the body which usually are not under
the control of volition. A few well people have this
in a marked manner, and in some hysteric or nerv-
ous states this power becomes enormously increased
and widened in range. I do not mean that these
people acquire the power to wdll intestinal trouble,
for instance, but that they certainly may gain ability
somehow to disturb the bowel functions by thinking
of them. There are many stories in regard to this ;
but let the average man endeavor by any mental
process to cause diarrhoea, and he will, I think, find
it no easy task. It seems incredible that a woman
can learn to vomit at will ; but this is common; and,
also, happily she can be taught to suppress this

60 DISEASES OF THE NERVOUS SYSTEM.

vomiting by volitional effort when the will is aided
by a potent motive.

Books like Dr. Tuke's are full of stories illustrative
of such facts, and I myself have seen a large number.
It is clear, then, that we can sometimes acquire such
control over functions supposed to be outside of
volitional rule, and that this is made easier in certain
temperaments and in states of hysteria, feebleness,
or nervousness.

The disturbances thus brought about lie usually
in the heart or vessels, or in the gastro-intestinal
tract, and are caused or aided by expectant attention
or dread, or by morbid watchfulness with a knowl-
edge of symptoms.

It has been said by Hunter, as quoted by Tuke,
that, if a number of men surrounding a table on
which they have placed each a hand, will fix their
attention on the member, some of them at least will
soon feel in the part a peculiar sensation. I have
tried this in vain, and I have also tried without
result to cause my heart to beat quicker by merely
attending to its action, yet I am myself of a rather
nervous temperament. It is curious to find John
Hunter avowing the ease with which he could in
this manner create symptoms, and then to find Sir
James Paget declaring himself utterly unable to pro-
duce mimicry of disease by any amount of attentive
effort. The difference among healthy men in this
respect must, however, be immense. Of this I had
once a curious illustration. When a very young
man, five of us made a series of what are called by
the homcBopathists provings of certain medicines,

MIMICRY OF DISEASE. 61

each man being ignorant of the drug taken ; three
of the live had a great variety of symptoms, but the
other two had none. It is well to add that the
symptoms corresponded neither among the observers
nor to those set down in the homoeopathic manuals.
My friend, Professor Tj'son, will recall an amusing
example of the effects of expectation in a patient of
ours. The iirst day he saw her, in order to use
electricity, she chanced to have at the time, as she
always had under excitement, a loose stool. This
took place also at his next visit; and thereafter he
never made a call at a set time w^ithout causing sharp
purgation. When he came unlooked for, then the
whole trouble left her. It brought to my mind the
case of an English physiologist, who happened to
have diarrhcea when about to give his first lecture.
The embarrassment and annoyance were great, and
so impressed him that for a year he never lec-
tured without having just beforehand a loose stool.
The sufferer chanced to relate these facts to a well-
known physician, then a very young man; being
himself also a biologist, he unluckily felt interest
enough in this matter to recall it when soon after
about to appear for the first time before an audience.
The excitement attendant on a novel situation, with
a knowledge of how it had affected another, caused
it to have a like effect on him, and for a long time
he was always thus anno^^ed when about to lecture.
I have given these as illustrations of increase of
action under mental disturbances and expectation or
dread. They could readily be multiplied. In the
two cases named, anxiety caused the repetition of a

6

62 DISEASES OF THE NERVOUS SYSTEM.

flow which was at first accidental, or, at all events,
not born of emotion alone. In like fashion arise and
continue certain of the forms of cardiac and vasal
nervous disturbances. First there is some sudden
and unusual influence disturbing the circulation ;
then, upon occurrence of lesser but like causes, a
similar trouble arises, until a morbid habit is fully
formed.

There exists in all of us, feebler in age and more
potent in childhood, a tendency to automatic and
unconscious imitation which is the parent of a good
deal of the mimicry of disease. It may exist in sim-
ple forms, or be emphasized by love, anxiety, fear,
or even by disgust.

I have said it vs^as potent in the young, and it is in
them responsible for a good many of the peculiarities
and resemblances usually set down to inheritance ;
but it is also to be seen at times in their elders.
Some months ago, I was showing to a physician a
very singular case of unilateral grimace. As I
turned from my patient, I noticed that the doctor
was repeating with his own features the morbid
action before him. I said, ''Do you know that you
were imitating this lad's grimace ? " "I know now,"
he said, " but I must have done it without conscious
imitation." Perhaps no better or more illustrative
example of the natural tendency could be given.
This was pure automatic imitation.

The tendency to cough, when forced for a long
time to listen to a cough, is an instance where ten-
dency to imitation is made powerful by sympathy or

MIMICRY OF DISEASE. 63

aftectioii. It may account for some, at least, of the
false wbooping-coughs we meet with.

A more amusing example is one which I have
seen several times, but which seems to have escaped
mention in print. It is the occurrence of vomiting
in the husband of a pregnant woman. The story of
one of these unlucky sympathizers is worth telling :

He was rather noted as an unfaithful mate and a
man of altogether loose ways. After Rye years of
marriage, his wife becoming pregnant — an event
much desired — he seemed to reform, and was very
much in her society. Her vomiting, which was
extremely severe, at last affected him in like manner,
every day or two, to his utter disgust. Her second
pregnancy gave rise to a return of his malady. I
believe that she ceased to be sick with her third
child — certainly with her fourth — but, so soon as on
each occasion he became aware of her state, his
vomiting came on, and lasted for a month or two;
indeed, I think, in one case much longer.

The character of his disorder at length became
known to his friends, and he was so mercilessly
chaffed that it was at last almost dangerous to men-
tion the matter. I have seen other cases — his was
the worst — but I was told of one in ^ew York, last
week, and the victim was a physician.

I may have overlooked something in my search
through the books for mention of these curious facts.
Prof Groodell reminds me of what Francis Bacon
says (Cent. x. Para. 986) : " There is an opinion
abroad — whether idle or no I cannot say — that loving
9.nd kind husbands have a sense of their wives breed-

64 DISEASES OF THE NEEVOUS SYSTEM.

ing child, by some accident in their own bodies."
Did he mean vomiting, or some more mysterious
diagnostic warning? In the Lancet there is brief
mention incidentally of a husband as having been
sick at stomach during his wife's pregnancy.

There could be no better examples than these
somewhat ludicrous instances of the influence of
automatic imitative tendencies. In the case just
mentioned, the habit became so strong that emesis
was reexcited by a mere knowledge of the fact that
there existed in the woman the state out of which
previously had grown the original trouble.

Instances of graver disease evoked in like fashion
have been given by Reynolds and Anstie, and always
it is found that fear, or the sight or the remembrance
of suffering in others, has been an eflicient means of
aiding the imitative tendency. In this manner trou-
blesome paresis, simulative of palsy seen in a relative,
has been produced. The condition thus acquired is
not a true palsy, and does not give us the full roll of
symptoms seen in the real case ; but it is something
more than a mere voluntary imitation, because there
is often a distinct incapacity for movement. The dif-
ficulty as to the amount of true pain felt in such of
these cases as mimic that symptom, I shall more than
once have occasion to speak of; and it follows us
everywhere in our efforts to appreciate fairly the ex-
tent of nerve irritation. It must bear to true pain,
perhaps, some such mysterious relation as the paresis
of these cases bears to true paralysis.

I saw last winter a young lady of highly nervous
and timorous organization, who was long under my

MIMICRY OF DISEASE. 66

care, and at length fully recovered. While in bed an
indiscreet attendant told her of the horrible agony
she had witnessed in a case of facial neuralgia, which
began daily about 11 a. m. A day or two later my
patient began to have pain in the same locality and
at the same hour every morning. She was one of
those women in whom you could cause pain any-
where by pressure on the spine, and a few suggestive
and directing remarks; and no more was needed
than the frequent mention of the torment of another,
and the remembrance that she herself had already
had what was called ovarian neuralgia. For some
days she really seemed to have an intense facial pain.
It wore away after I ceased to pay any attention
to it.

There is a state of mind and body, not rare in well-
developed hysteria, in which there exists a so mon-
strous development of this strange power to create
disorder by thinking of it, that even a slight hint, as
it were, will suffice to evoke a novel symptom. In
this disease, indeed, we find women, and men too,
passing into a mental state in which they are really
much hke people in dreams. Their power to reason
on the phenomena of the senses leaves them, and
what they conceive to be the case takes the place of
that which is. These are they who are hurt by light,
or believe^they are; who cannot bear noise, or think
they cannot ; who feel vibrations as pain ; who live
muffled lives in dark rooms, and believe they cannot
walk, or even lift a hand, or move the head. Such
cases are looked upon as simulations of disease by

6*

66 DISEASES OF THE NERVOUS SYSTEM.

some writers, and are, I am sure, prone to pass into
that evil stage of hysteria.

This tenclenc}^ is, of course, to be met with, to some
extent, in all grave hysteric cases ; but it is also, as I
have said, the ruling feature of a few. If you cause
such hysteric women as these to believe that you can
cure them, you enlist on your side their own troops,
for as you can create symptoms, so can you also create
absence of sj^mptoms. There is in all this something
like the so-called magnetizing of which we used to
hear and see so much. Under a fixed belief people
were made unable to move, or could not close the
eyes, or could not open them, or were made to seem
to have a pain by touching a point on the body. The
patients I speak of are all very subject to like delu-
sions. You put a finger firmly on the spine, and ask
if the patient have now a pain in the left breast?
She says no. You repeat. At last she says, ^' Yes —
Oh, it hurts me I" Now, is this pure sham, or is it
not? Does the presence of the set belief create
pain ? Is it like the pain of dreams, which seems
real enough while we are in the state of dreaming ?
I have tlaought over all this a great deal. When we
put a finger on the eye unopened for days, and say
"ISTow you can open it," and this is done; or when
we arrest motion by an order, we see a plain phys-
ical result which must have behind it a ganglionic
change out of which it grows; and so it seems to me
that, looking at the pain evoked by ideas or beliefs
in the light we get from the motor phenomena, so
evolved, we are hardly wise to stamp these pains as
non-existent.

MIMICRY OF DISEASE. 67

At the same time that I put forward this doubt as
to the justice of the common view, I am far from
thinking that the hysteric girl of the class I am now
discussing suffers as sharply as she seems to do; the
emotions are no more under control than in a dream,
and no pains are little, no burdens light.

I have now in my care Miss C. from Milw^aukee.
When I first saw her she was in bed, which she quit
but rarely and with diificulty. The room was kept
dark, and she wore blue glasses over the closed eyes,
and outside of all a bandage. She used cotton in
her ears, and her nurse and parents crept about in
list slippers. She had in all ten pillows, large and
small, as supports around her, and was, as a young
hysterical girl once told me, " crowded with symp-
toms."

The character of this girl had always been that of
a person thoughtful of and for herself, and not free
from esteem for her own mental powers, so that she
had been able and also very willing hy degrees to
rule a meek household with that reckless despotism
the throne of which is very often the couch of an
invalid.

This case seemed to me one in which set beliefs,
easily gotten and well nursed, had attained a power
which gave rise to pain and over-sensitiveness and
more or less inhibited movement. I began to deal
with it by learning all I could from the girl herself
to add to what I already knew of her mind, her
morals, her habits, tastes, friends, education, and
home life. Then the talk was allowed to settle on
her eyes, and at last on the uses of light, and the fact

68 DISEASES OF THE NERVOUS SYSTEM.

that its excess hurts even the healthy, but does not
injure them. When at last she grew interested, and
with herself for a text that was easy, I said, that per-
haps a woman of strong character might learn to
bear the light after long disuse of her eyes; that
such a one could not get well readily in the dark,
and that although the light would pain her, it most
surely could not cause disease. I then left her, with
the idea that she could in a few days conquer her
rebel eyes, and that it was absurd for a woman of
intellect to let one organ disorder the whole body.
The next day I found her with open eyes and sun-
light in the room. One by one the ideas on which
the case was built were thus artfully removed, and
she is now after but a few days of treatment far on
the road to health.

These victories are less easy with older women ;
but even then the mode of dealing with them is as
much a question of the basis of character as of any-
thing else. Sometimes we only need to dispel one
symptom to overcome all; sometimes the return to
health and healthy ideas exacts a long and tiresome
struggle. Sometimes it is safe to assure the patient
at the outset that she has but to believe and exert
herself in order to walk.

In this infirmary I saw, a few years ago, an abrupt
success obtained in this latter way in a woman, fifteen
years in bed, who was made able to walk well in
three weeks, and I could easily add, were it needed,
the details of many other and less striking cases.

I had meant to say something here of that form of
hysteria in which the patient deliberately acts a part

MIMICRY OF DISEASE. 69

and with more or less cunning deceives those about
her. I have seen a goodly number of these cases, but
among them I have found quite rare the attempt to
simulate palsy. It is easy enough to learn when a
woman is pretending to pass calculi or vomit snake-
bones, but to know if her loss of power be real, or if
she be suffering from an inhibitory idea or belief is
more difficult. I may say , however, that purely simu-
lated palsies in hysterical girls, lack the qualities of
hystero-palsies, are too complete, and show no loss of
feeling. The best cases I can recall were in very
young girls, and were present with much mental dis-
turbance, and after a long role of hysteric symptoms
had been played with success.

One of the cases I lately showed you was a curious
and most instructive illustration of imitation where
distress and terror at witnessing disease in a sister
were the efficient factors.

Mary C, aged nine, had frequent, sudden, and
severe attacks of epilepsy. After they had lasted
two years, the mother brought her to my clinic, and
with her a lad aged eleven. He was a puny, feeble,
pallid boy, easily alarmed, and so nervous that he
could hardly answer my questions. It seemed that
nearly six months before I saw him, he ran a nail
into his foot, and, about the time the wound healed,
had something like a hysterical attack, which seems
to have impressed him with the idea that he was
afflicted in the same manner as his sister. Soon
after this he had what the mother called a spasm,
whenever the girl was attacked, and still later when
he heard she had a convulsion, or at times without

70 DISEASES OF THE NERVOUS SYSTEM.

this suggestive cause. His attacks began with tremor.
He was said then to become insensible and to shake
all over violently. There was no tongue biting, and
no coma following the attack, and no facial spasm.
After becoming satisfied of the psychical origin of
his disorder, I ordered him a cold douche whenever
attacked, and directed that he should have the hot
iron applied to his neck if the attacks did not cease
in a month. At the same time the sister's fits were
controlled by bromides, so that he ceased to have
before him the constant incitement to attacks. With-
out further treatment, the boy's fits, if I may so call
them, promptly disappeared, not all at once, but by
degrees, and he is now well. That in this case the
fits of the boy were imitative is clear enough — that
without the model before him they would not have
arisen is plain.

We need not ask a cause for simpler forms of imi-
tation, as seen in normal functional acts, as when the
micturition of one in a herd of cattle awakens the
idea among the rest and leads all of them to follow^
the example. The imitative tendency is a useful part
of our developing powers, but here in cases like that
of this boy, where there are other children, he alone
imitates. Does the terror he only as a timid nervous
lad feels, intensify his imitative faculty, and what
motive is there for yielding to such a tendency? It
may be that there is a certain pleasure in giving way
to instinctive imitative propensities, and moreover
we must all have observed how some sick children
enjoy the important role of being ill, of being cod-
dled and attended to, and this is especially noticeable

MIMICRY OF DISEASE. 71

in large families, or in asylums, where usually no
one child receives in health undue attention. Such
aids as these there are, no doubt, to cases of mimicry,
while sometimes the patient's surroundings are to be
blamed, as fastening the disorder or even as giving
such information about symptoms as is consciously or
not applied to the perfecting of them, the actor re-
ceiving as it were, from a too sympathetic audience,
hints which enable him the better to sustain his part.

Some of you saw but lately the case which sug-
gests these remarks. Here, again, the actor was a
lad. The following details of his case I owe to his
physician. Dr. Benjamin Smith, of Falsington, in
this State :

0. F., set. 9, had at school a slight chill, and in the
evening thereafter headache and fever; he was well
next day, but w^as said to have had headache the day
following. At this date the doctor found him sufier-
ing from great tenderness at several points of the
spinal column. He could not recall having hurt his
back, but a few days later declared that he then re-
membered having fallen so as to strike the back, and
that the pain was severe ; also, that, on the same day,
he had fallen so as to hurt his head. Both falls were
said to have taken place on December 25th.

As soon as the tender spine and headache were
known to exist, the lad was kept at home and anxi-
ously cared for, while the pain in the head increased
and extended at last to the spine. At this date a
remarkable dilatation of the pupils was observed,
and, the pains increasing, he would lie in bed and
rub his head for relief, or have it rubbed. Mean-

72 DISEASES OF THE NERVOUS SYSTEM.

while Ms pulse was not above 80, and did not rise
with the presumed increase of pain ; nor did he lose
appetite.

About the fourteenth day the headache was said
to be at its worst, pains arose all over the body, and
the muscles of the neck began to be complained of
as sore and stiff, while nausea and pretty violent
vomiting added to the alarm which his case excited,
being set down, despite Dr. Smith's ojDinion, as an
attack of cerebro- spinal meningitis. At this time,
after the vomiting ceased, there was a sudden cessa-
tion of all the symptoms; but in a few days more his
troubles returned, and with dreadful complaint of
head and backaches, with universal soreness and
utter inability to walk, he was at last brought to me
for an opinion and for treatment. His case had then
lasted five weeks, and was supposed by some phy-
sicians and by his relatives to be of a dangerous
gravity.

When I saw this lad he was lying in bed, some-
what flushed, but not in a bad condition ; his pulse
was 85 ; his breathing 20 ; his temperature normal.
His eyes w^ere bright, and I was struck, as Dr. Smith
had beeii, by the widely dilated pupil. He was con-
stantly declaring that his head hurt him ; and it was,
as I observed, very notably retracted, the muscles of
the neck being stiff* and tender. Any effort to flex
the head gave rise to tears, remonstrances, and urgent
cries of pain. The scalp was everywhere tender and
the w^hole of the erector spinse muscles were also sore,
so that the least tap or touch upon them caused him
to cry. His legs were gathered up close to his body,

MIMICRY OF DISEASE. 73

and, besides some loudly expressed annoyance when
exposed to a bright light, he complained bitterly of
the vibrations caused by carriages passing or of the
steps of his nurses when they moved across the room.

If, however, he were interested in anything, I
found that I could flex the head or touch the spine
without causing pain until his attention was recalled
to the act. This — with the absence of fever, the
calm pulse, the fair appetite, and a certain watchful
and furtive expression — led me to believe that he
was more or less consciously mimicking disease. As
soon as I felt secure in my opinion, I lifted the lad
out of bed, and, with severity, ordered him to stand
up ; he hesitated a moment, and then dropped the
flexed limbs under him, lifted his head at a second
order, and, as I released him, walked to his bed — a
feat which he had been supposed to be utterly unable
to do. After this there w^as no trouble ; he was kept
out of bed, and, with a rough rubbing daily and a
little urging, was able to play in the garden in three
days, and to go home in a w^eek. His pains, stiff"
neck, and tender spine were never heard of after the
first day in the hospital. I was careful to have him
kept on a farm away from his home for some months.
There has been no relapse.

This case excited great attention, and was the
centre of the too affectionate regards of many rela-
tives. The lad became early aware that he was
believed to be in grave danger. His head and spinal
pains were attributed to meningitis, and the symp-
toms discussed in his hearing. Only thus can we
account for his curious condition, when, in the face

7

74 DISEASES OF THE NERVOUS SYSTEM.

of opposition founded on his presumably serious
state, Dr. Smith brought him to me.

I saw, some years ago, a like case in the person of
a young woman who had nursed two cases of cerebro-
spinal meningitis. Her imitation was admirable, and
for some days took in both her own physician and
myself

Careful use of the thermometer, and a rigorous
study of symptoms, can alone enable us to avoid such
traps as these. The}^ illustrate what may occur in
nervous people, under the influence of depressing
agencies, and when surrounded by too great sym-
pathy, and by ail the information needed to enable
them to act a part.

The lessons which such cases teach us are obvious
enough. The need for care in discussing symptoms
before nervous women or children, the necessity of
early apprehension of the true state of things in
simulated disease, and the wisdom of acting deci-
sively when once we are sure of our ground, are all
of them points on which it is hardly needful that I
should dwell.

In October, 1880, I was asked by Dr. Stryker to
see in consultation a number of cases at the Church
Home for Children, and, as these present the most
amazing illustration of mimicked disease I have
ever seen, I shall describe them as being the best
possible illustration of nearly every point on which
I have dwelt. The home is a handsome, wholesome
asylum for children, and is situated a few miles from
Philadelphia. It contained about 95 girls and but
6 boys. Both the sick and well, when I saw them,

MIMICRY OF DISEASE. 76

were amply nourished, and healthy-looking; nor was
it possible to find in their home or in their habits any
influences which could be credited with giving birth
to neurotic tendencies. The diet was good, the
hours regular, the play and out-door life sufficient;
neither was there in the education given, nor in the
religious training, anything with which it was pos-
sible to find fault from a medical point of view.

Dr. Stryker gives me in substance the following
account : Margaret Trimble, set. 12, a rosy and sturdy
brunette, in admirable health, is one of a neurotic
breed, there being in the immediate family two cases
of infantile palsy. On September 4th, in the dormi-
tory, when in bed at night, she began to have with-
out known cause, unless it might have been a trifling
indigestion, slight convulsive twitches of the arms
and legs, with a little numbness of the extremities.
This was a matter of a half hour, and she got up well
next day. There were no further attacks until the
11th, and thenceforwards they returned daily. At
first she was well in the intervals, and slept and went
about like the other girls. Her respiration during
the attacks was harsh and noisy, and she made at
each inspiration a loud crowing noise, much like the
breathing in croup. The attacks, rare at first, soon
became frequent, and lasted from fifteen minutes to
three hours; attention from others inevitably brought
them on, even when she was seated and laughing or
chatting with her companions. She would then slip
down, to the floor, and hands, feet, and body would
be seized with uncontrollable convulsive motions, so
that it was impossible to keep upon her person clothes

76 DISEASES OF THE NERVOUS SYSTEM.

or bed-covering. During an attack she lay on her
back, or rolled from side to side, while both arms
and legs thrashed the floor with quick and hard
blows. The body was lifted from moment to mo-
ment, and thrown down again wdth violence, in a
fashion strange to see. Meanwhile, her face was
contorted with swiftly changing grimaces, and the
tongue thrust out and drawn in, while her head was
thumping hard on the floor. Sleep w^as apt to fol-
low a fit; and there was at times, and later in the
case, a good deal of choreoid difliculty in moving,
or in handling objects ; at times the crowing existed
alone, and at times the legs became feeble, and she
stumbled and fell about.

This child was sent to the Hospital of the Univer-
sity of Pennsylvania, where she remained two
months, under the care of my friend. Professor
Horatio Wood. Dr. Musser, the Registrar, sends
me his notes, from which I add the following par-
ticulars :

The muscles of the face, neck, eye, and tongue
were at this time unaffected by the spasms. While
seated she swayed backwards and forwards in clonic
spasms. When lying down, her spasms were much
as I have described them. There w^as lack of co-
ordination in all arm and hand movements, but no
anaesthesia anywhere. There was tonic spasm of
the adductors of the thighs, and in a slight degree
of the flexors of the forearms. All movement ceased
in sleep. There was no lesion of the eye-ground.
The urine was normal. There was a slight systolic
roughening at the apex of the heart. The usual

MIMICKY OF DISEASE. 77

remedies for chorea having failed, the actual cautery
was twice used on the spine, but with no better for-
tune. Etherization on a full stomach caused vomit-
ing for twenty-four hours, and a permanent relief of
all the symptoms. Under careful and systematic
training of the muscles, with much urging, and a
good deal of scolding, she made finally a complete
recovery.

This girl's case was seen by many of her comrades,
and not only excited their amusement and curiosity,
but led some of them to imitate her " bark," so that
they were reproved by the matron for their tricks.

On September 8th, Dr. Stryker being in the home,
Kate Mchols, a wholesome looking girl of 10, was
brought to him in the nursery, in what seemed at
first to be a sharp attack of false croup. She was
breathing hard, gasping, crowing, speechless, and
wildly clutching at her throat. Her possible rela-
tion to the first case was not then understood, and
she was treated as if for croup. The trouble per-
sisted all day, and was noted as made worse by noise,
or any excitement, and to be by and by associated
with slight convulsive jerkings of the limbs. Mean-
while, the pulse was rapid, but there was no fever.
The following night all of these troubles passed away
in a sound sleep, from which she awakened crowing
and barking; and after a day of increasing nervous
agitation, exploded in a convulsion, identical in
character with that of case I^o. 1. The attacks
thereafter increased in violence, but all of her func-
tions were well performed. She ate, drank, and
passed urine and feces as usual; and when free from

7*

78 DISEASES OF THE NEKVOUS SYSTEM.

convulsions was merry and pleasant, until the ap-
proach of a nurse with medicine, or the visit of a
manager to the Infirmary, started her oft' anew.
From the outset she began to lose power in the
limbs. When held up, she would start fairly, but
instantly the legs became convulsed, the feet tripped
one over the other, and she fell in a fit on the floor.

The girl was also treated at the University Hos-
pital much as was the last case ; the cautery was of
little use, but the effect produced by ether on her
comrade had a decidedly good moral influence, and
seemed to have a good deal to do with her recovery.

Case 3. — On September 9th, Sallie Speer was seized
with the same form of respiratory spasm, but with
the crowing noise there was a continuous chattering
of the teeth, like that of a bad ague chill. On the
10th the usual convulsions came on, she having
ample preparation from seeing those of the other
children. In a few days all of her symptoms passed
away, and she returned to the school-room, for a
week, when the same disorders reappeared, and she
was once more placed in the nursery.

Case 4. — Florence Pierce, set. 12, had about the
11th like attacks; but, besides the usual convul-
sions, she had remarkable mydriasis in the intervals.
While yet able to walk, she had singular attacks of
festination ; and if going towards her bed, would
run furiously and be thrown headlong across it, and
on to the floor beyond. Generally she crawled about
on her hands and knees, with her head swaying
about as if it was held up with difliculty.

Case 5. — Miriam Drinkhouse, set. 11, was depressed

MIMICRY OF DISEASE. 79

on account of having been placed in a lower class
than her comrades, owing to her inability to keep
up w^ith them in their studies, l^ext day she was
unable to stand, and her first fit followed on October
13th.

Case 6. — Fannie Clark, set. 12, was taken ill with
respiratory spasms, and the same convulsions about
October 13th. She had, also, remarkable coldness of
feet and hands, which was not observed in the others.

Florence Mack, get. 8, Sarah IsTolen, set. 12, Florence
Mulligan, ^t. 10, Bella Burk, set. 11, Mary Mitchell,
set. 12, were all taken about the 12th to the 15th of
October. Their symptoms were much the same as
those above described. There were also a number
of other cases, some slight and some severe. Owing
to want of space, all the first cases were placed in the
two adjoining rooms of the infirmary. Here they
were seen by one another, and also more or less by
such girls as were engaged in the housework. Other
cases were soon added, and at last there were at
least ten cases in the apartments mentioned. The
results of this companionship may be easily imag-
ined. At first the convulsions were irregular as to
time, but after awhile they took place only in the
evening, and later still in the morning and the
evening ; although at any time a visit such as mine,
or that of Dr. Stryker, or of a lady manager, was
sufiicient to start the attacks. Then one girl would
begin to bark or twitch, then a second and a third,
until, on bed or floor, or seated, ten or twelve chil-
dren were wheezing, barking, grunting, crowing, or
in violent convulsions ; while the bewildered nurses

80 DISEASES OF THE NERVOUS SYSTEM.

ran from one to another, presenting a scene quite
astonishing to witness.

During a few clajs there were many interesting
variations in this singular malady. On one occasion,
all of the children in the sick ward got out of hed at
night, and took to walking ahout on their hands and
knees; at other times, some of them, speaking in
their sleep, described their visions. One saw black
men; another, whose mother had been recently
pregnant, spoke of herself as having had a child,
and mentioned the luxuries she considered desirable
for a person so situated. More commonly the girls
were scared, or said they were, by wild beasts ; and
one child would adopt the vision which another re-
lated within her hearing. After consultation, all of
the cases were scattered about among different hos-
pitals,^ where, as a rule, they made prompt recoveries
under somewhat various treatments. The cases
lasted from one month to three.

1 The Jefferson College, the Presbyterian, and the Episcopal
Hospitals. I am indebted to Dr. Starr for full notes of several of
the cases.

MIMICKY OF DISEASE. 81

LECTURE IV.

MIMICKY OF DISEASE.

The cases with which I have illustrated this sub-
ject of mimicry of disease have been, so far, some-
what simple and uncomplicated; nor could they have
readily or long deceived any watchful physician who
had had any experience of neurotic maladies. There
are, however, more complicated cases to be met with,
and some of these are remote from those so far de-
scribed, in that the symptoms were not imitated from
models ready at hand, or wholly learned from gab-
bling nurses or relatives.

They exhibit also the curious progress from simu-
lation, not consciously imitative, to conscious unre-
sisted simulation, and at last dissimulation. I shall
relate here two admirable instances of these inter-
esting combinations of mimicry passing into well-
sustained fraud.

A good many years ago I saw, one evening, a girl,
aged 13 years, who had never had any of the mala-
dies of childhood excepting measles. When her new
troubles began she was not as yet menstruating, nor
did she show any notable signs of womanly develop-
ment.

In January, 1866, when skating, her right instep
became chafed severely, and for this she was kept at

82 DISEASES OF THE NERVOUS SYSTEM.

rest for two or three weeks, but received very little
care from her mother, and, in fact, needed but little.
One day an attack of indigestion ended in vomiting,
which was very violent, and v/hich brought about
her all the sympathy her elder relatives could give.
From this time her appetite failed, and the vomiting
recurred at intervals. Long after, she told me that
she could have vomited less, but that everybody was
kind when she was so sick. Here, at least, was a
distinct failure to resist, and probably a desire to aid,
in producing sickness of stomach. The vomiting
grew more frequent in the spring, and after a fort-
night of fever, which she is said to have had in June,
1866, all food was thrown up, and the bowels v^ere
opened only once in ten days, or even less often.
These conditions persisted through 1866, with little
change, the child rejecting everything, and growing
at last sallow, and desperately wasted. The skin
became sensitive to touch, so that no water could be
used for fear of causing convulsions, and most of the
time she was shaken by violent hiccough.

The vomiting, at first accidental, was thus at last
aided and cherished for a purpose, until, as often hap-
pens, the morbid act became habitual and despotic.
But in a nervous system such as this child's no such
habit could persist without giving rise to other symp-
toms as grave, while these in turn w^ould be nursed
and developed to win and keep up the sympathy,
attention, and importance, w^hich are among the un-
natural moral appetites, of a nature once started upon
this disastrous road so strewn with multiple disor-
ders. When such persons get well, their lips are so

MIMICRY OF DISEASE. 83

surely sealed by shame and self-disgust, as to make
it difficult to verify by frank confession the suspicions
which arose in the minds of bystanders, or to trace
the fatal steps by which the victim descends, from
the state in which she welcomes a symptom, to the
degradation of creating symptoms. My patient, when
first seen by me, had been abandoned, as in a dying
state, by two homoeopathic physicians, who had left
for her use a prescription of rather ample doses of
morphia.

The picture which this child presented when first
I saw her was not readily to be forgotten. She was
lying on her back, staring upwards, with glassy eyes
set deep in dark rings, which faded into a sallow
leathery skin, drawn tense over projecting bones.
Her mouth was wide open, the jaw dropped, and the
whole cavity literally lined with thrush (muguet).^
The skin of the body was dry, and splotched with
islets of dusky red, and the bedclothes were kept ofi:*
of the sensitive surface by a shelter of half hoops.
As I stood and looked at this singular spectacle, ap-
parently that of a dying child, she groaned at brief
intervals, and also coughed a good deal, at such times
expressing pain in her face, but usually lying quite
still, with a look of merely the most profound melan-
choly. A careful study enabled me to find no organic
disease. Her urine was so scanty that she often
passed but two ounces a day ; but this was not albu-
minous; the belly was very tender to touch, although,

1 The coating of oidium albicans was the most remarkable I have
ever seen.

84 DISEASES OF THE NERVOUS SYSTEM.

if I distracted her attention, neither touch nor pres-
sure caused any sign of pain; attention was needful
to enable her to feel these pains, but as it may be said
that attention is for all pain a reinforcing element,
too much stress must not be laid on this point. I
noticed, however, that this w^retched, wilted, starved
creature followed my motions with attentive eyes,
although she never turned her head.

I asked for milk, and put within her lips a table-
spoonful, for which she closed her mouth; a moment
passed, and with a gulp she threw it up. I repeated
the dose, keeping a finger on the larynx. Again she
threw up, or seemed to; for, as the larynx did not
make the usual upward movement which accom-
panies the act of deglutition, it was clear that she
had not swallowed at all. I watched this neat little
fraud several times. Usually she swallowed a part
of each mouthful, and, holding the rest in her mouth,
suddenly cast it out with a very fair imitation of the
convulsive act of emesis. When quite sure of having
correctly observed her, I abruptly charged her with
the deceit. At first she denied in a faint voice, and
saying she couldn't help it, began to cry. A little
sternness enable me to get down her a full glass of
milk. I then cleared the room of all her friends,
threw aw^ay the hoops, and sat down by her side.
She was evidently conquered and alarmed, which I
did not wish her to be. I therefore took her hand
quietly, and told her that she could get w^ell ; that
milk was needful ; that, if thrown up, it would be
given again, and that I meant to feed her whether
she liked it or not.

MIMICRY OF DISEASE. 85

The after-care, which owed its success largely to
the care of Dr. Wm. W. Keen, was arduous enough.
The belly — and, indeed, the whole skin — was rubbed
twice a day with sweet oil ; milk was given freely
and often, and the bowels rid of their packed con-
tents by the use of frequent enemata. I found the
spine exquisitely tender, but, as is often the case, this
was much helped by ice-bags (dry cold). Meanwhile
the thrush faded under the use of washes of sulphite
of soda. The patient's head was elevated a little
day by day, and the diet was increased and varied.
The bowels proved so obstinate that nothing but
croton oil moved them, and the trouble of swallow-
ing persisted for some time, although lessened when-
ever her attention could be called away from the act of
deglutition. Incessant attention to the muscular ap-
paratus of the throat had made the use of these parts
difficult, and swallowing having ceased to be auto-
matic, was reembarrassed by every new concentra-
tion upon it of an act of will. When she received
milk in her mouth it always rested there for some
time; if, however, the head was thrown back, and at
the same time the larynx pushed up by a hand, this
sort of hint usually proved successful, and the move-
ment of deglutition was completed. By degrees this
trouble passed away, and she gained in strength so
as to sit up, and after awhile to stand.

The use of induction-currents to the disused mus-
cles was a further help, and, with the gain in power,
came back easier movements of bowels and bladder,
and a more wholesome moral tone. Within six

86 DISEASES OF THE NERVOUS SYSTEM.

weeks the girl was able to call at my house, and she
is now, I believe, the healthy mother of a family.

I could never extract from this child, "when well,
anything beyond the statement that she ^' just could
not help it;" and if I pressed her further, she said
she was sorry, and took refuge in tears.

A^bout two years ago I saw, with Dr. Finn, a case
quite as remarkable. The girl, aged thirteen years,
living in Ohio, after an attack of ague, began to limp
a little one day, and said she had a pain in the right
knee. A physician examined it, and told her parents
quite truly that there was no cause for alarm, ad-
vising at the same time exercise, and a let-alone
treatment. This w^ould have answered well, and
have saved much trouble, had not some one per-
suaded her mother to ask advice of the travelling
agent of a surgical institute, who diagnosed hip-joint
disease, put on a temporary splint, and arranged to
cure the child at the institute. From this time, when
the little public opinion about the girl pronounced
for a grave malady, she grew speedily worse, and
under the influence of the discussions as to the hip-
joint disease and its symptoms, she began to act out
as fully as possible the pathological drama so fool-
ishly taught her. The pain increased, and the leg
contracted at the knee and hip. At the institute
things grew^ worse, and very soon there was double
hip disease, and local applications, and splints, many
and wonderful. But when one of these curious cases
is well engaged in this career of simulation, there
comes a time when, either because the first trouble
no longer excites sympathy, or for more complex

MIMICRY OF DISEASE. 87

reasons, these forms of disease become progressive
and invasive. In our little patient, the contractions
of the thigh remaining, the arms, especially the left,
became flexed, the feet being in full extension. At
this time hysterical spasms came on ; the eyelids
closed, and remained shut; and, most strange of all,
she was unable to eat before 9 o'clock p. m. In this
state the child was first seen by Dr, Finn, who re-
moved her to quiet lodgings, where soon afterwards
I saw her, and heard this exasperating history of
folly and quackery. As I first saw her, she lay on the
bed, her back to the light — a queer little shrivelled
creature, tawny of tint, and the skin covered with
bran-like scales, washing being a rare ceremony.
Legs and arms were drawn up so as almost to hide
the thin, ancient-looking and cunning little visage,
which seemed so blind with its closed but quivering
lids, and yet so unnaturally astute in its intentness
of attention when her own case was mentioned or
discussed.

Her right hip was red and swollen, and the thumbs
of both hands had been so long and tightly con-
tracted as to have caused the palms to ulcerate, while
the whole skin was sensitive to such a degree that
the bedclothes were not allowed to touch her, and
she uttered a muffled cry of dismay and seeming
terror at every approach ; her voice was reduced to
a faint whisper, and she was said to be totally blind.

The treatment in this case was of easy enough
application in a child. A single nurse was left in
charge. The legs were violently straightened and
their owner invited to set them in order, so as to

88 DISEASES OF THE NEEVOUS SYSTEM.

avoid in future this abrupt and painful treatment.
We were told as usual that she never could eat until
nine p. m., and wonder was expressed that, having
her eyes shut, she was able to know what o'clock it
was. The clock on the mantle was an obvious aid,
and at all events, when set forward two hours, the
nine o'clock meal was asked for at seven. The gain
in this case was steady and easy enough. I lost sight
of the child after she left us to return home, but at
the time of her departure she was nearly well, and,
I learn, has entirely recovered.

I have often thought that, if I could induce older
patients who had been affected more or less like
these children to relate to me their histories with
sufficient frankness, I should obtain a larger insight
into the motives which prompt them to cultivate or
to create symptoms. As interesting additions to
this rare branch of medical autobiography the three
letters which I subjoin must suffice :

"The period of my life about which you ask me,
I can only look back upon with a sort of disgust
which makes it unpleasant for me to speak about ;
it is only the hope that some one else may be helped
by it w^hich makes me willing to speak of it at all. I
was brought up by an invalid aunt, and I often think
of what you once said to me, that the women who
indulge their own nervous systems are those who
most indulge children. My aunt taught me very
early to notice and dwell upon any little symptom I
happened to have, and, when I was fourteen, I un-
luckily hurt my knee. For this I was kept in bed
two weeks, and, when I wanted to get up, I was told

MIMICRY OF DISEASE. 89

to keep quiet. Under this enforced rest my appetite
failed, and I began to have nausea. My first vomit-
ing created a sensation in the household, which I
think, as I recall it, I enjoyed as making me im-
portant. Very soon I got to vomiting every day;
there was none of the nausea which I had at first,
and which I have since been familiar with as a part
of sea-sickness. It gave me no annoyance to cast up
my food, and was, indeed, rather a relief. From this
time I was surrounded with sympathy and doctors.
A few months later my aunt died and I was left in
charge of an uncle and aunt, and became one of a
large circle of children, among whom I got very little
of the care which had before this encompassed me.
I remember well that I resented the change, and,
finding that if I took little food I excited alarm, I
began to yield to the tendency to excite distress and
anxiety by taking little or no food at times, I sup-
pose this abstinence gave rise to the nervousness,
and finally to the spasms which came on at this time,
at least I can give no further explanation; I only
know that every new symptom caused new anxiety,
and that I somehow liked it all. After a while a
new doctor was called in, and under his rule, which
was very stern, I got better, and was able to leave
home and go to the seashore, where, under new in-
fluences and interests, I lost all my symptoms except
the vomiting, which seemed to me uncontrollable.
I lost this only by resolute efibrts; in fact, by efforts
so desperate that often, when food rose in my mouth,
I swallowed it again. I do not think I should ever
have so tried if I had not overheard a person in whom

8*

90 DISEASES OF THE NERVOUS SYSTEM.

I had a great interest express himself as having heard
with disgust of mj habit. Tlien, as you know, I
learned from you that the habit could be broken; I
succeeded, as you know, and am married and have
a little girl, and I can promise you that she at least
wdll never be allowed to go through what I have
done."

I presume that this partial self-analysis is as near
to a full and truthful statement of the motives which
urge to mimetic fraud as we are likely to get. I
have been told by one woman that she was as irre-
sponsible as one in a dream; while more usually you
are told simply " I do not know why I did it; I could
not have meant to deceive any one." My next ex-
tract from these confessions is in some sense honest
enough, and, as I said before, is curious, both as to
what it reveals and what it hides. The writer is long
since dead, and I am therefore at liberty to use her
letter with such precautions as make identification
impossible.

I had seen my patient in the morning and received
this letter in the evening. For several weeks she
had been under my care with these conditions, a good
rosy color, fair weight, and regular functions ; but at
times enormous losses of urine and intense spinal
irritability, which forbade her to stand or to walk a
step. For her food she ate a chop at breakfast, and
no other food the rest of the day. You must not
understand me to say that I accepted all these state-
ments, but merely as briefly sketching what seemed
to be her state. This very pretty invalid was a charm-
ing and witty, and most accomplished person. After

MIMICKY OF DISEASE. 91

her husband's death, she had taken to her couch, and,
despite aches and ailments, was in her becoming sick
outfit the centre of an attractive circle, which gladly
gathered about the couch, on which she was carried
from room to room. I hardly know under what
circumstances she developed the full range of her
powers. The irritable spine came first, and as one
doctor after another was consulted other symptoms
were added to her repertory.

She had been some little, while under my care,
when I saw two things which confirmed my well-
grounded suspicions as to the nature of her case ;
she slept alone, disliking the constant presence of a
nurse ; but she rarely failed to ring for her attendant
twice every night.

The last morning I saw her, I had occasion to look
at her feet, and noticed that her soles were dotted
with black marks ; coupling this with the fact that
she had complained of her wood fire as having
smoked, I concluded that she had been afoot in the
night, and that the dark marks came from "blacks"
on the floor, the result of a defective fire draught.
A moment later, observing some crumbs on her
bolster, I asked her to sit up that I might examine
her spine. As she rose, I threw aside her pillow,
and saw under it two oranges, several slices of bread,
and a banana. To my amazement she said cooly,
" Well, now I am caught; I thought you would do
it soon or late." My rather sharp remonstrances
seemed only to amuse her, and that evening I re-
ceived the 1 etter, a part of which I print.

" Before this reaches you I shall have made ar-

92 DISEASES OF THE NERVOUS SYSTEM.

rangements to leave. The game I have played on you
I have played on others, and in my restricted life I
have found it very amusing. You must not blame
my maid, as I paid the woman who cleaned the room
to bring me food. I found that doctors got tired of
my sore back, and that they ceased to feel interest
in me, a thing I never did like, so I began to com-
plain of queer symptoms; and as this often aroused
new interest, I went on experimenting until I hit on
the starvation idea, which has done very well. Of
course I got up at nights, and walked a good deal
too, but how you knew it I would like to know. As
to the urine, I used to fill up the vessel with water.
I hope you will not tell my doctor at home, you
would take away a good deal that is pleasant, and
spoil an interesting case, too.''

These are the only cases of this form of moral
obliquity in which I have ever been able to get a
free confession. They expose, I fancy, to some ex-
tent, the motives which underlie the duplicity of
such women.

The last of these statements is more recent, and I
have permission to print it. It is in some ways more
valuable than the others; the belief this woman at
last reached as to the want of foundation for her
presumed physical disabilities, and her continued
conviction that the pains were as distinct as any
pain, must, I think, be received with respect. I am
sure that she has done her best to analyze her symp-
toms truthfully.

She came to me on a couch, or litter, from a
Western State, a o^irl of 19, not wasted, and of good

MIMICRY OF DISEASE. 93

tints. She was said to be unable to walk, motion
hurt her; and her eyes were carefully guarded from
light by a double bandage. She was kindly but
firmly treated, and was able in a few days to bear
sunlight, and to go downstairs. When once she had
been made sure that all this could be done without
death, I allowed her to go forward more slowly, with
such help from tonics, good diet, etc., as I could give.
She very often talked to me about the cause for her
disorder, and out of my inquiries and interest in her
case came the self-analysis I append. It needs no
commentary.

" I suppose, in all cases of nervous affections, one's
natural temperament and constitution play an im-
portant part; and, doubtless, with me, a tempera-
ment rather emotional, sensitive, and occasionally
morbid, had something to do with making possible
the state I was in when I went to see Dr. Mitchell,
in December, 1879.

" The immediate cause for the headaches, which
began a year before that time and never left me after
it, seemed to be a few weeks of mental and social
strain. I had for two years before that time suffered
from a weak back, had felt constantly tired, spent
much of my time on the bed, and taken but little
exercise. But in the fall of 1878 I felt much better
and undertook study and class recitation, and became
much interested in some evening literary and social
clubs. For a few weeks I went every day to the
utmost limit of my strength, and was then suddenly
prostrated with severe headache and excessive weari-
ness.

94 DISEASES OF THE NERVOUS SYSTEM.

" I, of course, tried quiet and rest immediately,
and after a while grew better, but had a return of
headache and weariness whenever I tried exerting
myself much again. There is no question that what
I lacked then was courage. If some one could have
told me that there was nothing of consequence the
matter, I am sure I should have overcome the diffi-
culty and very soon have gained endurance by exer-
tion ; but, instead, I became afraid to do things for
fear of bringing suffering; and, as month after
month passed, I could do less and less. I cannot
now understand why I could not have seen — why I
could not realize that the less I did the less I could
do ; but I was blind, and so was everyone else. I
thought it was some strange, mysterious disease that
was taking away my strength. By summer, a few
minutes' conversation or the walk of a block would
make the pain in my head agonizing, and every
sound became unendurable. My eyes, too, shared
in my good-for-nothing state.

" In the fall, the pain went into my back and
limbs, and sent me to bed with the strange infatua-
tion that I could not move without injury, as I cer-
tainly could not without pain. I had laid in one
position with closed eyes for eight weeks, before
going to Dr. Mitchell, in a state of supposed help-
lessness. One thing I want to say in extenuation of
myself, and that is, that the pain was real, not
fancied. Whatever its cause, or however easily it
might have been averted, it was genuine suffering
at the time. I was scarcely ever hysterical, either,

MIMICRY OF DISEASE. 95

in the usual sense of the term, for, at least, I realized
the necessity of self-control.

^' In looking back over that year with the light of
the present, I can only say that I believe there wixs>
nothing really the matter with me, only it seemed
as if there was ; and, because of those sensations, I
carried on a sort of starvation process, physical and
mental. Why that process should have brought me
into such a condition, I must leave with some one
wiser than I to unriddle."

96 DISEASES OF THE NERVOUS SYSTEM.

LECTURE V.

UNUSUAL FOKMS OP SPASMODIC AFFECTIONS IN

WOMEN.

You will find, if you come to have much experi-
ence in the cases of hysterical women, that in some
instances the disorder arises in general convulsions
following upon a state of acquired nervous instability,
and then runs on into a great variety of symptoms
— palsies, hyperaesthesias and anaesthesias and con-
tractions— to end, at last, in years of bed-ridden
invalidism, or, much more rarely, in spinal sclerosis.
A single case will thus give jou, in disorderly and
unexpected succession, every scene of what 1 have
ventured elsewhere to call the drama of hysteria.

At the risk of repeating an old story,! have sought,
in one of these lessons, to relate some of these his-
tories, chiefly that I might illustrate afresh the
termination in sclerosis, and partly to show what
might be done to rescue certain of what seem to be
the most hopeless of these exasperating cases.

Apart from these, however, we see two forms of
hysterical disorder, in which the primary signs are
either slight and aborted, or remain so inconspicuous
as to give but little aid in the early diagnosis. One
of these is marked by mental derangements, and is
usually treated as simply a causeless insanity until

SPASMODIC AFFECTIONS IN WOMEN. 97

some outbreak of the commoner forms of hysteric
signs reveals the true condition. I mention it here
only to complete my rather rude and partial classifi-
cation. The other is characterized by the extraordi-
nary variety and strangeness of the convulsive dis-
orders, which, for years, and from time to time,
afflict the patient ; all other symptoms being present
rarely, or in feebly repi^esented forms. I propose to
relate and discuss for you some of the most unusual
of these cases.

In 1871, I was consulted by an intelligent unmar-
ried lady, Miss L. P., set. 26, from Mississippi, for a
condition of system which was probably due to cer-
tain emotional disturbances following a violent onset
of cholera morbus. The attack was repeated a few
days later. The day after, she had intense, burning
pain between the shoulders and down the whole
length of the spine. This symptom lasted long, and
with it, for a month, during which she kept her bed,
there were brief periods of febrile activity. She is
said to have had no severe headache, and no uterine
or urinary symptoms. On first rising she found that
her legs were feeble, and this paresis was best marked
on the left side.

When first seen by me these symptoms remained
unchanged. The weakness of the left side was com-
plained of both in the arm and leg, and as affecting
the eye. She needed a supporting arm when walk-
ing, but did as well in the darkness as in the light,
and stood fairly well with shut eyes. The left sole
was slightly less sensitive than the right. Above
this there was no dyssesthesia. There was also no

9

98 DISEASES OF THE NERVOUS SYSTEM.

analgesia, and heat and cold were well distinguished.
There was, at times, a sense of extreme weight on
the chest. The burning pain in the spine was un-
equally distributed. It was worse at the 5th and 6th
dorsal vertebrae, and was increased at night and by
fatigue. The temporary application of ice made it
worse, and this increased sufiering was felt for some
time afterwards. Elsewhere she had no fixed suffer-
ing, but complained of darting neuralgic pains almost
at any point of the body. There was no womb trouble
of moment. On the left side there was a large area
of variable iliac tenderness, not great, and sometimes
absent. It was less on deep pressure than on slight
touch. The eye-grounds were normal, but she was
said to have at times double vision, if very tired.

This case, as I recall it, puzzled me greatly, and
was finally treated as of organic cerebro-spinal
origin ; and this idea was strengthened by the fact
that at times there was distinct rigidness of the
erector spinse muscles. She came under my care
first in the autumn of 1872, and gradually improved.
The back was several times cauterized early in Jan-
uary, 1873, and great gain followed. Somewhat later
a slight and singular tottering of gait was seen ; but,
on the whole, the progress was good and steady ; so
that, by the end of January, 1874, she could walk
with ease a quarter of a mile on level ground. In
February, 1874, Miss P. made the mistake of leaving
home, and subjecting herself to what was, for her,
excessive fatigue and much social excitement. Then,
as always since, fatigue brought on more or less
nervousness, and the singular forms of spasms which

SPASMODIC AFFECTIONS IN WOMEN. 99

have proved so enduring an annoyance. At the close
of a day of unusual fatigue, on rising from her chair
to cross the rooni, she suddenly staggered back, and
then rotated violently several times. These fits re-
turned over and over, and resulted within a week in
fresh dorsal pain, extreme lassitude, and a curious
inability to keep her balance. Meanwhile, the rota-
tions were usually, but not always, to the left. The
loss of equilibrium was great. On rising she would
pitch forward, and then sideways, and then turn
swiftly. The pitching was really convulsive, and
not due to lack of balancing power, and there was
no subjective sense of giddiness. She came to see
me soon after, and was much worse for the journey.
During ten days of quiet here the rotatory spasms
gave place to violent and nearly constant spasmodic
jerking of the head backwards or forwards, to right
or to left. As this also departed she had a new
onset of what she called "twists," and thenceforward
turned only to the left. These spasms were amazing
things to see — suddenly, while crossing the room, she
would rotate furiously to the left, about three to six
times. The turn was very rapid, and seemed to
begin with the spine. Then the head followed, and,
as she said, it seemed hard for the legs to keep up
with the back.

At other times an irresistible power seemed to
drag her up on to her tiptoes, where she would re-
main a moment, as it were, fixed. At this time she
could walk, or even run, backwards, but a forward
naovement was beset with difficulties. She would
be, as it were, hurled forward, and then rotate, or

100 DISEASES OF THE NERVOUS SYSTEM.

the effort to move in a forward direction would end
in a rapid retrogressive stagger, followed by rotation
to left. There was no vertigo except as a result of
the spinning. In June she went home, and from
this period she had a succession of slow gains with
sudden relapses. If leading a very quiet life, she
sometimes passed six months without spasms.
Worry, fatigue, excitement, were all sure to bring
them on. At times there was no warning, but
usually pain in the feebler leg, nervousness, and
irritability were premonitory of an attack. Then
she M^ould of a sudden find one leg oddly twisted
around the other, or would be drawn up on to her
toes, or forced to walk on her heels, or would pitch
hither and thither, not from weakness, but from
alternating unilateral spasms. At these times her
will seemed to be absolutely suspended. "It is,"
she says, " as if some other will-power had me in
possession. I struggle against it in vain."^

The first point to notice in this case is its generic re-
lation to the class of functional spasms of Duchenne;
those in which spastic movements are associated with
or follow some form of normal muscular action.
Such spasms do not arise during repose, and in this
sense chorea is at first, and in some cases throughout,
as I have elsewhere observed, a form of functional
spasm. ^ Perhaps I shall, in a measure, clear your
minds as to the nature of what I mean by functional
spasms if I recall to you the influence of strychnia in

1 For analogous cases see Eussell Kejmolds's System of Medicine,
art. Chorea.

2 Am. Journ. Med. Sci., October, 1876.

SPASMODIC AFFECTIONS IN WOMEN. 101

large doses — such as you have seen given here many
times. You will remember that in certain spinal
maladies, such as those of syphilitic birth, it is my
habit first to give iodides in heavy doses, and then to
suspend these for a time, and to give strychnia up to
the limit of physiological endurance, that is to say,
until I cause an approach to spasms. When, for ex-
ample, you give hypodermically the one-fifth to the
one-eighth of a grain daily — the patient will have
little or no annoyance if you are careful to insist
that he remain at absolute rest in bed for two hours
after each injection. If there be any tendency to
spastic twitchings of the muscles, the will is com-
petent to control them, unless, and this is the point
I would make, the patient attempts to exercise.
Should he do this, the eftbrt results at once in irregu-
lar movements of an incoordinate character, and in
slight or more grave spasms of the muscles em-
ployed. While at rest there is no obvious trouble,
but voluntary movement occasions spasms, which are
the offspring of the poison. They are, in a word,
functional spasms, and would not be seen at all, with
limited use of strychnia, were it not for the efforts at
voluntary action.

The second consideration to which it is worth
while to call attention was the great variety of the
forms assumed by Miss L. P.^s attacks, and the tem-
porary limitation of the disorder to partial groups of
muscles. These facts alone would, I think, entitle us
to suspect hysteria as a cause; and, when we learn
that no attacks ever took place in the street, and that
pleasant surroundings lessened the likelihood of the

102 DISEASES OF THE NEKVOUS SYSTEM.

occurrence of the spasms, while all depressing and
enfeebling agencies were apt to bring them on, no
further doubt should exist as to the parentage of the
disorder. Muscular action perfect in health loses in
force and in sureness, and in steadiness, as any one
falls away from the highest standard of physical con-
dition, and when there is in the ganglia some cause
tending towards irregularity in any shape, it also is
apt to rise into gravity just in proportion to the failure
in physical status. Add to this emotional disturb-
ances, which in certain natures are prone to express
themselves in some form of irregular muscular acts,
and we have all the needed factors for producing such
convulsions in persons at all capable of evolving
them.

I consider that the treatment, which I need not
here describe, utterly failed. I never succeeded in
raising my patient's health to such a level as to put
her above the possibility of these curious attacks. I,
perhaps, ought rather to say that I never could keep
her at that level. The least blow to health was with
her a knock-down, and recovery was slow. Prac-
tically speaking, the woman who habitually has
hysterical spasms has something wrong with her
general health. She is anaemic, or has lost general
tone, and cannot get up, so to speak, or there is that
remarkable state of easy tire which is called nervous
exhaustion, but which were often better called nerv-
ous exhaustibility, and which is, perhaps, due to
some form of defective nutrition of the nerve cen-
tres. Always there is some such cause behind the
spasms. If we can relieve it we cure the convul-

SPASMODIC AFFECTIONS IN WOMEN. 103

sions, or rather make the soil fatal to their growth.
I do not think this is always possible. There are
some ansemias which resist all treatment. There are
some mysterious forms of nutritive failure which are
never made well.

I have seen recently a case which somewhat re-
sembles Miss L. P.'s. Miss C, a native of Maryland,
set. 21, was sent, when 17 years old, to a school in
which boys and girls were educated together. Just
before leaving home she had two slight attacks of
"stiffness" when rising from the sitting posture.
While at school she never menstruated, although
previously regular. E^ext came a light attack of
diphtheria, and still her general health seems not to
have been obviously damaged; but the ''contrac-
tions" grew more frequent until at last one day, in
class, she was unable to speak, owing to trismus
which came on as she rose to recite. She went
home after this event, and in a few weeks her men-
strual flow returned; nevertheless the spasms con-
tinued, and this despite a gradual rise in health, and
a nature free from melancholy, and prone to seek
and find healthy enjoyment in outdoor life. A fur-
ther gain followed a residence of some weeks in the
West, but still the attacks continued ; nor did it
seem that almost perfect health secured immunity.

At present, in 1880, this young woman looks in
admirable condition; nor is there, on careful study
of her case, any evidence of organic disease or func-
tional disorder. While seated she never has any
symptom of spasm; but many^times in each day,
when rising from a seated or recumbent posture, she

104 DISEASES OF THE NERVOUS SYSTEM.

is seized with attacks which I have now seen her
exhibit many times.

On rising she is seized with spasms of the legs,
neck, face, and arms and hands. These vary end-
lessly, and are not often exactly alike in any two
attacks. Usually the phenomena are these, and in
this order :

Just as she begins to move, after rising from a
chair, she has —

1. A stiffening of the muscles of the legs, and
chiefly of those of the thighs. This causes a certain
constraint in her first steps, but does not prevent
them.

Having moved a few steps, she has —

2. A consentaneous spasm of the neck (twist to
left and downward pull) of the body ; also to left, of
the lower part of the face, either to left or right, or
stiffness from bilateral spasm of face. The left arm
is sometimes in violent flexion from fingers to shoul-
der, or the arm is extended and the hand fiexed.
There is the same variety as to the movements of
the right arm. When I last saw a fit, the right arm
and hand were thrown out in rigid extension, the
left being as perfectly in flexion.

3. 'No matter what posture was assumed, she was,
so to speak, fixed in it for perhaps ten to fifteen
seconds. The spasm came on, and rather slowly
culminated in some one odd posture, and there and
then the woman became, as it. were, a statue for the
moments that followed.

4. These spasms were painless, and disappeared
in an instant.

SPASMODIC AFFECTIONS IN WOMEN. 105

5. They caused no confusion, or vertigo, or any
other ill feeling, nor any sleepiness. She went on at
once to do whatever she had meant, such as to walk
or to dance.

At times the attacks are frequent, at others rare,
and absence from home and change of scene and
climate seem to lessen the number of fits.

6. These spasms are often, but not always, pre-
ceded by a condition which is sometimes chronic,
at others comes only as an immediate warning of
attack ; at all events, its presence is a sure sign that
the attacks will come on readily and be more than
commonly hard to prevent. This precedent state
consists in a slight general tingling which varies in
amount, and is apt to be accompanied by a sense of
stiffness in the muscles of the legs. These are rather
evidences of a chronic and slight condition of spasm
than of anything which it is worth while to call an
aura.

If, on rising, she stands still a moment and pre-
pares herself to walk by some indescribable mental
act, which is not a mere resolve, because here the
will is quite powerless, she can prevent an attack.
To rise quickly and walk at once, or to turn abruptly
just after beginning to walk, are apt to cause fits.

The relationship of such attacks of functional
spasm as these is as near to chorea as to epilepsy, for
the state of which she speaks as favoring and pre-
ceding a fit cannot for reasons already given be
looked upon as an aura, and we know of no epi-
lepsies in which the functional and orderly act of a
muscle or muscles gives rise in some way to the

106 DISEASES OF THE NERVOUS SYSTEM.

irregular and disorderly discharge of nerve force
which constitutes a spasm. But in grave chorea,
this is precisely what does occur, the forms of spasm
having of course in that disorder, as in functional
spasms, differentiating peculiarities. I gave this
woman bromide of lithium, chiefly to see if the
bromides would control or lessen the fits. The
attacks were not lessened by this agent.

After this failure I was at a loss how to deal with
the case. There are spasms which are so nearly a
part of the normal muscle acts or so tied up with
them as to be as hard to change by medicine as the
orderly sequence of any common muscular action,
nor is the task of reform more easy when years of
repetition have made deep the easy ruts of habit. I
could only insist that she must live so careful a life
as never to rise without being on guard. Then also,
since violent exertion distinctly lessened her ten-
dency to spasms, I advised an abundance of exercise.
The results of this advice were good, and the case
rapidly prospered when she took to hard housework,
which happened to interest her very greatly.

The next case which I desire to add to this group
of spasmodic disorders, is, like the last two, remark-
able for the great variety of distorting forms assumed
in turn. Some of you may recall the patient, a poor
unmarried seamstress, aged forty-three, tall, thin,
and with a face constantly and deeply flushed; a
pulse of 90 to 100, and, so flir as I could discover,
no organic disease. When nearing the age of forty
she began to have retarded menstrual flow, but
neither then nor when seen by me a year later, was

SPASMODIC AFFECTIONS IN WOMEN. 107

there any uterine trouble. In June, 1878, after some
family annoyances, she had a severe rigor, ending in
trismus which came on abruptly, and repeated itself
thereafter with like suddenness, and at inconvenient
seasons, usually while she was eating. In August it
was replaced by dysphagia. She acquired, as a
consequence of this condition, a deadly fear of the
abortive efforts to swallow, and would chew for
many minutes before making an attempt at degluti-
tion. In the autumn this too passed away, and in
October she first consulted me at my clinic for a
" lump " on the chest. I was about to refer her to
one of our surgeons when her remark that it went
and came interested me, and I carefully examined
it. To my surprise the growth was in or on the left
great pectoral above the breast. It was an oval
flattened swelling with quite abrupt edges. If I
carried the arm out so as to make the muscle tense,
in a few minutes the tumor disappeared gradually,
and I perceived that it was a phantom tumor with
which I had to deal. I was familiar enough with
these as seen in or on the belly, but I now saw only
my second case of this phenomenon in anj^ other
muscular mass. The " tumor" was hard and dense,
and the temperature over it was a half degree above
that of the neighboring parts. Hard rubbing gradu-
ally dispersed it, but it formed again in a few hours,
and I may add was always tender.

I next found to my great interest that all of the
pectoral on this side was in a state of curious irrita-
bility, and this you will recognize as only an increase
of a normal quality. When, for example, I strike a

108 DISEASES OF THE NEKYOUS SYSTEM.

healthy muscle with a finger-tip, or better, a pointed
caoutchouc percussion-hammer, such as that which
we use to test tendon reflexes — two facts are observ-
able. First, the whole length of the muscular fibre
struck contracts, or a large part of the whole length.
Then, as it relaxes, a little hard prominence forms
in the muscle at the part struck, and remains for a
few seconds until it gradually disappears.^ In this
woman's case, the secondary local contraction was
larger than is usual, and lasted for at least a half
hour or more. A few weeks later, she came to the
hospital to stay, and now the pectoral tumor had
gone, and the belly presented the usual appearance
of a phantom tumor. All of its muscles were
violently contracted, so as to look like a rounded
growth. It was painfully tender and the percussion
note was dull. It, however, presented one peculiarity
I had never seen in any other such case. Several
times a day the whole contraction passed away, but
the least handling of the belly brought it all back,
or this took place without any interference. The
woman was during all this time in a state of amazing
nervousness, and w^as seized with universal tremor
whenever any one came near to her bed. Her pulse
rose at times to 130, and the temperature fluctuated
daily and irregularly from 97° F. to 105° F. We
got her well enough to walk about and to leave the

1 I described these phenomena very many years ago in the Trans,
of the Phila. Acad. Nat. Sci., not then being aware that Weber
had called attention to them. They are best seen in the pectorals
of thin people.

SPASMODIC AFFECTIONS IN WOMEN. 109

hospital, but the abdominal contraction still existed
or did so after a year had passed away.

I have seen a similar false tumor in the calf of a
highly hysterical lady. It was relieved in a week or
two by the daily use of massage.

I shall complete this group of cases by a very
singular one, which I saw last year. M. B., female,
set. 59, a worn-out school-teacher, always feeble and
lacking blood, but otherwise well, had a slight sprain
of the knee, which forced her to remain at rest.
Very soon she perceived a rhythmical spasm of the
middle of the muscular masses of the calf of the left
leg. The muscle gathered into a hard painful swell-
ing about five inches below the popliteal space. The
contraction, which was two by three and one-half
inches in size, was sudden and horribly painful, and
the region attacked was always sore, but was most
so during the spasm. This lasted a few seconds, but
the space affected was at all times hot and a little
hard. The spasms were singularly regular, about
twenty-five to thirty a minute, but there were often
long periods of one to five hours during which no
spasm existed. She had been treated in various ways
without relief, but I was finally enabled to help her
by rest in bed, the use of a splint, and careful feeding
and iron, but the local trouble was not entirely cured
until I had used several injections of atropine, which
were thrown into the muscle, a plan which was, I
think, first employed by Drs. Morehouse, Keen, and
myself, in the Hospital for N^ervous Diseases during
our civil war.

To complete the group of unusual forms of spasm

10

110 DISEASES OF THE NERVOUS SYSTEM.

in women, I shall only add a case or two of hysterical
athetosis. Since Dr. Hammond first described this
interesting member of the family of choreoid spasms,
I have seen two cases in which the athetoic spasms
were simulated in hysteric women. One of these I
saw but once, as it did not return to my clinic ; the
other was a private patient, and was long under ob-
servation.

L. C, 8et. 25, from Canada, a stout, ruddy, unmar-
ried woman, was probably overworked at puberty in
acquiring accomplishments which she can no longer
use. At 14 she had diphtheria, but no sequent palsy.
The hysterical aspects of her case are represented by
tendency to tears, by rare hystero-epilepsy, by fits of
hysteric coma, by great nervousness, distress at loud
sounds and bright lights, and by general abdominal
tenderness. Over and above these it is to be re-
marked that she has a certain general feebleness, not
at all suggested by her look of health, nor is she ever
very steady in her motions, and is liable to a fine
tremor, which subsides only after she has been for
some time at perfect rest. Also there is a slight but
distinct and very slow oscillation of her eyes, so that
this group of symptoms suggests sclerosis. Other-
wise she is well, and it may suffice to say so without
going into negative details as to sensation, motion,
reflexes, and the functions in general.

Possibly this is an hysterical woman with an or-
ganic malady, but to which cause shall we refer the
athetoic spasms, which I shall now describe ? When
for relief the hands lie closely locked on her lap,
save for tremor, little movement is to be seen, but

SPASMODIC AFFECTIONS IN WOMEN. Ill

when released, and especially during excitement or
attention to them, both hands, the left being the
worse, exhibit the most singular motions. The
fingers extended, or in extension and flexed on the
palm, move to and fro, coming together or sepa-
rating, or crossing the line of the thumb. These
motions are slow, and of a perfectly disorderly char-
acter, but they never cease except in sleep and during
efforts at any manual work, when they are always
replaced by the slight tremulousness already alluded
to. In Dr. Hammond's case, at least in the one
given as a type, the movements continued during
sleep, and also they were powerful, and there was
some pain in the limbs concerned, but none of this
applied to my patient. The motions could be easily
controlled by another's hand, the resistance being
but slight, while also there was no pain. When,
however, my patient grew excited or emotional, the
movements became rapid, and during her menstrual
periods, which were natural, this was also the case.
There was no spasm in the feet. The history of
these movements is that thej arose out of a succes-
sion of hystero-epileptic fits, Vv'ith intervals of stupor,
or of stupor with rigidity. At the close of these
attacks, although she was in other respects well, the
fingers were noticed to be strangely affected, and
the disorder thus begun grew slowly worse.

The only question is as to the origin of these
spasms. Is it an athetosis proper, or an hysterical
imitation of athetosis, or merely athetosis grown, as
one might say, on an hysterical soil, and modified
by its place of growth ? Despite the fact that the

112 DISEASES OF THE NEKVOUS SYSTEM.

athetosis arose directly out of hysterical disorder, I
incline to the latter view, especially as in many par-
ticulars the case otherwise conforms sufficiently to
Dr. Hammond's admirable account. I ought to
add, however, that in cases more clearly and purely
hysterical, athetoic movements are sometimes met
with.

In my second case, that of an unmarried woman,
Miss J., set. 40, there were slight mental disorder,
sensory delusions, left hemiansesthesia, an hysterical
temperament, and slight ovarian tenderness (left).
Rapid relief of the mental trouble was obtained
under treatment, with slow improvement and final
cure of the anaesthesia, large gain in flesh and blood,
and entire recovery from the hysterical symptoms in
general. During the early months of the case there
were at intervals attacks of athetoic spasms. Usually
these came and went without appreciable cause.
At other times emotion, especially terror from her
sensory dreams, seemed able to occasion them. They
lasted from five minutes to hours, were not violent,
conformed absolutely to the type cases, were bilate-
ral, but ceased in sleep, existed only in the hands,
and several times ceased when Miss J.'s attention
was diverted.

The character of these motions diflfered somewhat
from the utter irregularity of Hammond's disease.
I should say they differed unless her attention was
called to them, in which case no semblance of order
in the spasms could be seen. When unwatched by
the patient, the motions consisted in constant slight
to and fro and lateral movements of all the fingers,

SPASMODIC AFFECTIONS IN WOMEN. 113

but at brief intervals. A large range of motion
would affect first the thumb, and then in turn all of
the fingers in succession from the forefinger to the
little finger.

As this woman improved in general condition the
finger spasms slowly passed away, and have now, I
believe, been absent for at least a year. Whatever
doubt there may be as to the hysterical origin of the
former case, none can exist as to the last one, so that
we may, I think, rank hysterical athetosis among the
forms of clonic spasms seen in this peculiar disorder.

10*

114 DISEASES OF THE NERVOUS SYSTEM.

LECTURE VI.

TEEMOE.

In accordance with the plan I have followed here
of treating at one time of groups of symptoms, at
another of single symptoms, I shall ask your atten-
tion to some of the minor forms of motor disorder
found among nervous or hysterical women.

The subjects I shall choose are Tremor, or tremu-
lousness, and certain Spasms, usually local, which
are not within the range of hystero-epileptic states,
but coexist with perfect consciousness.

You have seen here over and over the tremor of
tobacco, of alcohol, of lead, of old age, and also the
forms of tremor which are yet more active, such as
are met with in shaking palsy and sclerosis. Besides
being thus an expression of weakness, as in old age,
or fatigue, or the feebleness of convalescence, or of
organic disease, or toxic states, tremor is a sign in
many people of transient emotion, of fear, of excite-
ment, of anger, or of grief, almost as natural a motor
expression in some mobile natures as the facial fea-
ture spasm, laughter or crying, is of uncontrolled
mirth or grief. Tremor like these, too, is capable,
under certain circumstances, of passing over the line
of healthy functional manifestation and becoming a
symptom of disorder and lack of emotional control.
Here we are to consider it as a symptom found often

TREMOR. 115

among the nervous, a symptom which may be local
or general, temporary or enduring, and may, in a few
cases, be so much the most prominent feature of a
case as almost to constitute a disorder deserving of
being itself labelled as a disease.

If the organic tremors, the offspring for the most
part of coarse textural changes, be clearly spinal, it
is interesting to ask if the representative tremor of
hysteria be in like manner of functional spinal birth,
a question more easy to ask than to answer; but
seeing the volitional control which many nervous
patients possess, as regards the symptom tremor, it
seems probable that, in extreme cases, the cerebral
ganglia lose those inhibitory qualities which are
usually active in the healthy. That, however, this
symptom may be of mere emotional origin, or de-
rived from pathological changes, becomes important
in diagnosis where it sometimes chances that a spinal
malady is painted on a background of hysteria, or
that hysterical additions arise in emotional patients
to disturb our belief that we have had to do with a
malady purely organic. These mixtures of symp-
toms are, as you will readily admit, when you have
seen many such cases, as bewildering as charades.
Some of you may recall the case of Miss M., aged 25,
a fat and ruddy person, who suffered first from over-
study, combined with some mental worry. At the
age of fourteen she had diphtheria, but no sequent
paralysis, and came to me a few years ago, at this
clinic, a person looking as little like having organic
disease as any you are apt to see. About three years
before I saw her she had had an unfortunate love

116 DISEASES OF THE NERVOUS SYSTEM.

affair, which had ended in a high degree of general
nervousness, a form of trouble which we have very
frequently had occasion to bring before you, and the
symptoms of which, I trust, are now familiar to you.
It came on rather abruptly, as these things some-
times do, resulting in a tendency to tremor, which
was excited by the slightest emotion, or the least ex-
citement or worry, and was always worse at the time
of her periods. We have also intercalated, in her
case, a brief history of occasional hysterical spasm,
with spinal and ovarian tenderness. It seems prob-
able that on top of this came a condition of organic
disease of the spine, which is not as yet fully de-
veloped, but which will in all probability end in a
general sclerosis, of the character which we call
disseminated. She has now some slight difficulty
in walking, vague pains through the limbs, some
numbness of the feet and hands, and slight diffi-
culty of speech, a certain drawling of her words,
quite characteristic of the condition in question; she
has, too, occasional vertigo, and the disk of her left
eye is, I think, suspiciously white, while I find, upon
careful examination, that the vision of that eye is not
nearly so good as on the other side. The peripheral
appreciation of colors is distinctly impaired, so that
there seems to be only too much reason to fear that
the optic nerves are suffering from atrophic change.
The tremor she has at present may have been origi-
nally, and probably was, purely hysterical, since it
came and went, and was more or less within control
of the will. It has now all the characteristics of a
tremor from organic cause. She cannot thread a

TREMOR. 117

needle at all, or eat easily, or carry a full glass to the
mouth without violent agitation; while the hands are
for the most part quiet when at rest. Looking at the
whole of the peculiarities of this case, it seems to me
extremely probable that it has passed quietly, and
without the suspicion of her physician, into a state
of organic disease of the spine.

You are, of course, aware that there are two forms
of tremor in connection with spinal troubles; I may
coarsely state their peculiarities as follows : One is
constant while the limb is at rest, and is lessened by
motion; and the other is less when the limb is at
rest, and is made very much worse by voluntary
motion. The tremor of nervousness, and that which
is seen in hysteria, may be always constant except in
sleep, or may come and go irregularly, without ap-
parent cause, but will always be liable, like some of
the spinal tremors, to remarkable increase under ex-
citement or expectation, or the sense of being watched.
It is usually a tremor of variable extent, so to speak,
the range of disturbance, w^hat I may call the width,
being greater than that of most organic tremors, at
least at their beginning, while under the influence of
emotion, or without known cause, it may pass into a
condition of local or general convulsions, the range
of motion increasing like the lengthening oscillations
of a pendulum. In one respect, however, it distinctly
differs from the tremors of organic origin, which are
never notably controllable by the will; whereas,
in people merely nervous, or hysterically nervous, it
is nearly always possible greatly to limit, and some-
times for a time altogether to efface the tremor by a

118 DISEASES OF THE NERVOUS SYSTEM.

sturdy effort on the part of the patient. The form
of tremor of which I am now speaking, may be con-
fined to one limb, or may be so general, that almost
every part of the body may be agitated by it, and in
these latter cases, if the muscles of the face suffer
also, they are apt to exhibit larger movements, rather
than the finer tremors which affect the limbs. I re-
member only too well the case of a lady, from one
of our neighboring counties, which bafiled us com-
pletely, a year or two ago in this hospital. She was
a woman, aged 82, thin, not anaemic, in fact, rather
ruddy. The disease began about four years before
she came to me, and was a general nervousness and
neurasthenia, caused by a long spell of nursing two
of her family through fatal maladies. At the close
of this effort, which is always one of the greatest
strains that can be put upon a woman, she broke
down with hyperpesthetic conditions of the senses,
with tender spine, with great fatigue on the least
exertion, and with a general failure of her nutritive
functions. I do not remember when the tremor
began, which was so marked a feature of her case,
but I think it was a year from the time of the first
outbreak of her symptoms. When alone in her
room, and thinking herself unobserved, she was
usually quiet, except for a twitching movement of
the face, but when anybody entered, and especially
when I myself approached, she was seized at once
with a universal tremor and with extreme general
nervousness, so that speech became inhibited, and
deglutition was palsied for a time.

For some months, at least, the movements were of

TREMOR. 119

this character, and only after a time grew what I may
call larger. This was also the history of each onset
of shaking. The motion rose from tremulousness
through large tremor visible to the eye everywhere,
into a tremor which had in it a certain character
of violence, and was varied with occasional slight
jerks of the limbs, and accompanied with perpetual
agitation of every muscle of the face, so that she
presented an appearance not less singular than dis-
tressing. This may pass as a good case, in fact, as
a rather remarkable case of general tremor, but you
will understand that this symptom in less marked
degree is very often to be found as an expression of
all nervousness, and even of weakness as in conva-
lescence or in old age, while but few old hysterical
cases escape without more or less exhibition of it.

Localized tremors, I mean such as are absolutely
confined to one part, are somewhat more rare, nor
do I remember to have had the opportunity of ex-
hibiting to you here a single illustration of this class.
I have now under my care, however, a very interest-
ing woman, who has in both limbs below the knee a
condition of tremor, which is about as fair an exam-
ple of what I mean as anything that I have recently
seen. In her it was caused by a long strain of nurs-
ing followed by a disastrous railway accident, in
which though she herself was not injured, one of her
parents was killed. It was her general condition
for which she came to me, and the tremor is to be
regarded as only one symptom. I was told that
some time ago, she was the subject of general tremor.
She seems to have now a condition of mind not very

120 DISEASES OF THE NERVOUS SYSTEM.

rare among highly nervous women, and which with-
out much straining of language I might effectually
describe as mental tremor. A moment of mental
indecision seems to trouble her in regard to every-
thing upon which decision is necessary, she revokes
her opinion, again decides, and so, but with far more
uncertainty of mind than is shown in her speech,
comes at last to a conclusion. Her general condition
is exasperated by hysterical anorexia, by some dys-
phagia, and by perpetual and distressing tendencies
to micturition, and by violent flushing of the face.
Under the influence of tonics, and careful treatment,
she utterly failed to improve, but since I have placed
her alone, in the care of a nurse before unknown to
her, and steadily fed her every two hours, with also
the daily use of massage, she has so rapidly im-
proved, that now there remains very little of these
conditions excepting the tremor of which I have
spoken, but not fully described. While her hands
are perfectly steady her feet are most of the time, or
were most of the time, in a state of tremor caused
by incessant minute activity on the part of the flexors
and extensors of the feet, while there is also a good
deal of trembling of the leg and thigh. It has less-
ened from above downwards. However quiet her
limbs, my visit is sure to set them going. She has
been taught since she came here to restrain these
movements by act of will, at flrst for a minute, and
now for an hour at a time. Aided by the gain in
general health, this training of the will has proved
efficient, and there is at present hardly any tremor
in the right leg, while that of the left is fast disap-

TREMOR. 121

pearing. A well- applied bandage in some way helps
her, perhaps, as she says, by keeping her so reminded
of the limb as to be able to dominate it.

A year has elapsed since I wrote the last sentence,
and she is now entirely well.

What else need be said of nervous or hysterical
trembling has been already spoken of in connection
with my remarks on the subject of general nervous-
ness, to which it is so apt to be related. What I most
desire here is that you should never confuse it, as you
may easily do, with other tremors, but I must have
said enough to warn you on that subject.

Alcoholic tremors can only concern us in their
diagnostic relationships, and it will suffice if I say,
that as to this tremulousness, and as to other neural
symptoms, you should be constantly alive to the rare,
the very rare possibility that your patient may owe
some of them to the secret abuse of stimulants. I
say the rare possibility, because in a long and large
practice among women of the best social class, and
the one presumed by some people to be prone to
this vice, I have seen but five or six cases of alco-
holic drunkenness. I well recall a sad case which
was brought to me some hundred miles on a couch,
on account of a shocking state of universal tremor,
with attacks of prolonged stupor and rarer hystero-
epileptic attacks. The woman had been " diagnosed
at," as she told me, by many doctors, and took a ma-
licious pleasure in showing me a number of opinions.
The tremor was incessant and large, but did not
become worse for my visit, although it was at times,
I thought, purposely exaggerated, the patient being

11

122 DISEASES OF THE NERVOUS SYSTEM.

distinctly pleased at the importance of the role she
was playing. I confess, that I too should have been
deceived as to this case, had it not been for a practice
which you will do well to acquire, a practice now
become with me a deeply confirmed and increas-
ingly active habit of noticing in a room, not only
the patient but everything else. Missing a bottle of
cologne from its usual place, where I was apt to make
use at times of its contents, I said, ''Where is your
cologne?" " My maid upset it," she answered; " she
upset it on the table yesterday; she is very awkward,
and did the same thing last week." My eyes natu-
rally turned to the table, which was of antique ma-
hogany, varnished. Now, I had observed that when
cologne falls on varnish it permanently whitens it,
but this table was clean of spots. I repeated my
question, and when the same positive answer came,
I was suddenly sure that she was drinking cologne,
and this proved to be the case. We wrung from
her and her maid a sad tale of the fraud and strata-
gems by which she had been able to indulge in this
singular habit undetected for years.

CHRONIC SPASMS. 123

LECTURE VII.

CHRONIC SPASMS.

Chronic spasms persistent through months, or
even through years of waking life, are rare enough
among women, but exceptionally rare among even
the most nervous men. The only cases I recall in
these arose from nerve wounds. In my book on
Injuries to ISTerves I quoted but one case, which I had
myself seen. I saw others which had suffered from
violent spasm as an immediate consequence of a ball-
wound, and where, however, the spasm lasted but
a few hours ; but was in one case so great that the
nails of the spastically shut hand cut the palm
deeply.

You see, therefore, how uncommon is the condition
of true chronic spasm, and why, therefore, it pos-
sesses so much interest.

The chronic spasms of women with h^^steria are,
perhaps, among the most obstinately unmanageable
of all the graver symptoms of this disorder. They
are said at times, by the books, to make sudden re-
coveries. My own experience as to this is the same
as in hystero-palsies. I do not see abrupt recoveries
— why, I cannot say — perhaps because the cases
which reach me are always old ones, much treated.
At all events, you must have seen enough here to

124 DISEASES OF THE NERVOUS SYSTEM.

know that we earn our triumphs, as a rule, by intel-
ligent and patient care.

These chronic spasms may affect almost any part.
You are apt to see the jaw locked; I have seen it
kept rigidly open. I have seen the head bent on to
the breast, and so held for months. The false tumors
of the belly are local spasms of muscles ; such a case
I saw last year, with Dr. Sinkler, who must well
remember how the immense tremulousness told us
what was the constitutional cause of trouble before
the woman could uncover her supposed tumor.

Sometimes you will see these very local contrac-
tions in a part of other muscles. I once saw two
large, permanent tumors in the calf of the leg.
They were merely contractions of muscle, and not
of the whole, but of a part, and, like some of the
abdominal contractions, were very tender. They
came very near to being removed by a surgeon —
who, too often, made his diagnosis with the knife.

I have, however, made mention of some of these
cases in a former lecture, and need not dwell here
on this especial form of the trouble in question.

Permanent spasms, then, may affect almost any
muscle of the body, and be so violent and lasting as
to excite our amazement that, through many years,
in some cases, a few groups of ganglionic cells
should be competent to evolve such enormous
amounts of force. I recall from my notes one case,
which was, I think, a very interesting illustration of
these affections, and which is also worth mentioning
to you, on account of the success of the treatment,
and because of the various therapeutical experiments,

CHKONIC SPASMS. 125

for experiments they must largely be in the treat-
ment of this disease, which were made by others or
by myself. This young lady, Miss C, from Mary-
land, was brought to me a few years ago, as some of
my assistants may remember, with violent spasm of
all the anterior muscles of the right thigh and leg,
the foot, however, being extended. The rigidity of
the limb was something extraordinary — it stood out,
when erect, at absolutely a right angle to the body,
and no pressure that I dared to use w^as competent
to depress it notably without causing extreme pain,
and soreness of the stretched muscles. When the
hand was placed upon the anterior muscles of the
thigh they could be felt to be in a state of tremor,
as though not all of the muscular fibres were acting
at once. Probably, owing to the long-continued
action of the muscles, the limb was never entirely
relaxed in sleep, nor during the many months she
was at the hospital was it ever seen to be in any other
position than at a right angle, or at an angle of 45°
with the line of the erect body. A multitude of
therapeutic experiments ending always in failure,
and the abandonment of the case, had been made by
several ph^^sicians; nevertheless, I undertook the
treatment with a certain amount of hope, such, in
fact, as I always have, when an hysterical case is
taken away from her own home and social sur-
roundings, and subjected to new and revolutionary
influences.

I began the study of her case by placing her seated
at the foot of the bed propped up with pillows, and
then suspended from her ankle an increasing amount

11*

126 DISEASES OF THE NERVOUS SYSTEM.

of weight, to learn whether I could by degrees de-
press the limb, and thus wear out the muscles. I
have, however, seen her carry a weight of fifty pounds
for three hours, and she was but a frail girl, without
the limb falling more than a few inches. Under
ether the limb relaxed, but there always remained a
certain amount of rigidity, owing, I presume, to
what I may call the setting of the too long-contracted
muscle.

Long before the ether left her, the spasm returned,
and, therefore, I was quite sure that it was not one
of those forms of mimic spasms of which I have pre-
sented to you some curious examples. I next made
an effort to wear out the spasm by the use of induc-
tion-currents, using two batteries, but although I
employed such a power of the batteries as could not
readily be sustained by any but an hysterical woman,
I did not succeed in my efforts, and she remained
much as before. The use of galvanism to the spine,
no matter what might be the direction of the cur-
rent, also failed. She was finally cured by very much
gentler treatment, which consisted in the use, twice
a day, of the fullest hypodermic injections of atropia
she could bear thrown directly into the rigid muscles.
As soon as the atropia began to show its power in a
certain amount of relaxation of the limb, I also had
the limb manipulated, having it moved in different
directions, upwards, downwards, and sideways.
Under this treatment she steadily improved, and
finally left the hospital able to walk on crutches,
with the limb nearly straight under her, but still
unable to employ it in walking. By this time she

CHRONIC SPASMS. 127

had obtained a certain amount of volitional control
over its action, and in a few months became entirely
well. There are cases, however, in which steady
extension of the flexed limb, or steady flexion of
the extended limb by apparatus will succeed in
overcoming this rigidity. Of this I have seen an
excellent example in the case of Miss "W., also
from Maryland, who came to me with the diagnosis
of general sclerosis, but who really presented one
of the most extraordinary illustrations of hysterical
symptoms which I have met with in years. She
had at one and the same time some general palsy,
a profound loss of power of the left leg, anaesthesia,
and chronic hysterical spasm of the right leg, with
violent alternate spasms and extensions of the head,
together with a quite marked amount of mental
hebetude, somewhat rare in such forms of hysteria.
To make her case still more difiicult, I may add,
that she was fat and rosy, in perfect condition, men-
struating with ease and regularity, and apparently
suflfering from no organic trouble whatsoever. I say
to add to the difficulty, because I always feel more
hopeful of a case of hysteria when it occurs in the
person of a woman lean, wasted, and ansemic. You
have then, of course, the chance when building up
a constitution, to aid your moral treatment by all of
the profound alterations which you may bring about
during the process of fattening, and fllling with good
blood an exhausted system. In her case I succeeded
in extending the limb by the use of a screw^ appa-
ratus, and a stirrup fastened to the extended foot,
and attached to the apparatus below the knee. Per-

128 DISEASES OF THE NERVOUS SYSTEM.

haps the anaesthesia of the limh may have aided me
in this matter, but, as I have said above, it is not
often that you succeed by these means, and in using
them you may expose your patient to a second dis-
order in the form of general convulsions, or local
spasms in parts remote from that first affected.

I saw an example of this in the case of a lady
whom I went to Massachusetts to see, some years
ago, and who sufi:ered from atrocious chronic spasm
of the left arm, so that it was always painfully flexed.
There was no anaesthesia of the limb, and every
effort to make it straight gave rise, if persisted in,
to general convulsions, which finally caused, as 3^ou
may imagine, the total cessation of all efforts in that
direction.

The treatment of these forms of spasm must usually
consist in the treatment of the general condition, and
of what that is, I have already fully spoken, in speak-
ing of the general subject of the course of hysteria.

I said in 1881, when these lectures were first
printed, that section of tendons in hysterical con-
tractions of muscles was uuadvisable. I have now,
after two years, to modify this statement. During
this interval I have thrice seen section of the tendo
Achillis prove valuable.

In another instance, where, in despair, I cut
several tendons, the contractions returned with vio-
lence ; but in all of these cases the first and interest-
ing effect was sudden arrest of the spasm.

The cases which did well were all of them young
women whom I had succeeded in lifting to a higher
level of health, and in whom, as a consequence, all

CHRONIC SPASMS. 129

the hysterical symptoms had faded away, excepting
this single obstinate spasm of the calf muscles.
The relation of one case may suffice:

Miss L., set. 15, who had passed through many
forms of hysteria, and at last grown sound enough
to resume her usual studies, returned after. two years,
remarkably well, with the one exception of a con-
stant spasm of the calf muscles. When she left me
two years before, I had hoped that with improving
health this last relic of hysteria would pass away. I
was surprised to find that it was as bad as ever, and
that she was absolutely without any other hysterical
symptom. The spasm was most violent and always
was worse for any efifort to flex the foot, or from
prolonged walking. It certainly seemed that, as
splints and atropine and all else had failed, we were
justified in using the knife, yet I could not but fear
that after section of its tendon the muscle might
continue in a state of spasm. Dr. Sydney Roberts,
who shared my doubts, divided the tendon, the patient
being under ether ; but the retreat of the released
muscle was not extreme nor spastic, and to my
pleasure, when the tendon reunited, there was no
return of spasm, the power of the muscle was normal,
and I had learned a useful lesson. Certainly in this
case the tension kept up by the tendon was a condi-
tion of the existence of spasm. There has been up
to this time — a year having passed by — no return of
the trouble, nor of any other hysterical phenomena.

When, then, you meet with chronic spasm in the
hysterical, deal first with all the possible causes of
the constitutional state; and only when you have

130 DISEASES OF THE NERVOUS SYSTEM.

succeeded in relieving this can you hope to see the
spasms get better by any of the local means I have
mentioned.

Spasms such as these, are not often purposely
mimicked, but occasionally you will meet with an
illustration in this form of that unconscious simula-
tion of disease, if I may be allowed such a phrase,
of which I have already so frequently spoken. In
this disorder there occasionally arises a chance for
the success of those abrupt impressions upon a
patient which so amazes alike the sufferer and her
friends. I recollect, as an illustration, the example
of a very charming young girl from Rhode Island.
When I first saw her she was lying on the bed, with
her knees drawn up, her feet not extended as is
usual, but flexed. I was told that when she awoke
ill the morning, they were straight, but were almost
immediately drawn up into the state in which I saw
them. After going over her whole system and not
discovering evidences of organic disease, I finally
made up my mind that it was a case for one of those
bold experiments which sometimes succeed when
more timid action fails. After inducing her mother
to leave the room, I suddenlv straightened one of
the girl's legs. I met with no difiiculty until I had
partially attained my object, and this proved to me
with certainty, that it was a willed spasm with which
we had to deal, and not one controlled by volition.
I then said to her, '' I have straightened one of your
limbs, straighten the other for me." She said, "I
cannot, but perhaps you can." I straightened it
with but little difficulty. I then said, " Sit up on

CHRONIC SPASMS. 131

the side of the bed." She replied that she had not
sat up for years, but I finally got her seated with
much trouble, and then, picking up a gay cravat,
and tying it around her neck, I said, laughing, "iTow
you are all dressed for a walk, how amusing it would
be to meet your mother at the door." To my sur-
prise she yielded, seeming to enter into the fun of
the idea, and with a staggering gait (such as you
would expect from one long confined to bed) she
advanced with me to the door, where she met her
astonished parent who was just coming into the
room. She never went back to bed again perma-
nently, and in a few weeks afterwards was able to
ride on horseback.

You now and then meet with cases in which the
whole range of hysterical phenomena leap into mis-
chievous life owing to some most trivial wound or
other hurt, but it also chances at times that a real
and grave injury of a nerve may give you an almost
indistinguishable mixture of nutritive and other dis-
orders the usual result of nerve wounds, and also of
hysteric symptoms such as may perfectly well arise
without traumatic cause. It becomes then almost
impossible to say of a given symptom, such as
chronic spasm, which may be the child of either
parent, whether it be hysteric or due to the nerve
lesion, and yet as concerns treatment, it may be of
the utmost moment to reach such a decision. The
follovv^ing case is a remarkable illustration of my
meaning.

I saw last year, wdth Dr. Morton, P. L., set. 26, a
maid-servant, who had, a year ago, a fall in which

132 DISEASES OF THE NERVOUS SYSTEM.

she bruised her left side. Being of a nervous and
impressible nature, it was not surprising that she
was seized at once with left unilateral numbness
and slight loss of power. These symptoms faded
away in a few daj^s as one of the minor injuries due
to her fall rose into mischievous prominence. In
falling, she struck her left elbow so as to cause pain
down the arm, but not in the ultimate distribution
of the ulnar nerve. Five days after the accident the
pain grew w^orse, and a general hypersesthesia spread
over the ulnar side and middle of the arm. At the
same time the lingers began to ilex more and more,
until at last all the finger-tips and the thumb came
into contact in the position assumed when with all
of the fingers w^e hold some small object. The hand
was held in extreme and constant flexion chiefly by
spasm of the palmaris longus, the tendon of which
was rigid and prominent. The least eftbrt at passive
motion of the parts caused intense pain, and the
hypersesthesia was so great that a touch on any part
of the fingers, except the thumb and forefinger, and
on nearly the whole forearm seemed to occasion the
utmost distress.

This case, I confefes, somewhat puzzled me. I^erve
wounds of themselves give rise in either sex to hys-
terical states, so that, except for my knowledge of
the previous temperament, this condition was of
little diagnostic aid. The hyperaesthesia was ex-
treme. It is so in many nerve wounds or contusions,
but, at least early in the case, it does not pass out
of the distribution of the nerve presumably affected.
lu this case it did not seem to have any accurate

CHRONIC SPASMS. 133

anatomical site, that is, it was partly in the ulnar,
and irregularly there, and in a portion of the median
and musculo-spiral territories ; while there was none
of the tactile loss which inevitably accompanies
nerve lesions, there being agonizing pain, and yet
lack of accurate sense of touch. Besides this, in the
present case, the lingers were cold ; there were no
joint lesions, nor any causalgia or nutritive changes
in the skin or nails. When, too, I pressed on an
indifferent point — such as the olecranon process —
and led her to believe that I was compressing a
nerve, she described her increase of pain as terrible.
Either, then, this was a case of slight nervous lesion
exasperated by the hysterical temperament, or else
it was not a nerve hurt of any gravity, and all of
the symptoms had arisen in consequence of a trivial
hurt, just as a pin-prick may be the starting-point of
the most extreme and enduring hysterical phe-
nomena. It would, I think, be difficult to find a
better illustration of the difficulties in reaching a
distinct diagnosis in such cases, and yet a diagnosis
is here, if in any case, most desirable, because, if the
case be purely due to contusion of the ulnar nerve,
the question of operative interference is certain to
arise should the symptoms continue long. This
woman was put under the daily use of galvanism to
the arm and hand. Each application was followed
by relaxation of the contracted parts and by a lessen-
ing of the hypersesthesia. When the poles were
applied without making circuit, the same results
followed, and I have now not the faintest doubt that

12

134 DISEASES OF THE NERVOUS SYSTEM.

the phenomena were from the beginning to the end
of purely hysterical parentage.

There is a form of spasm which is sometimes mis-
taken for paralysis, and is to be met with, as far as
I know, only among women; that is to say, in a
large experience I have never encountered a case
among men; it is what I might call spasmodic
ptosis. It is to be distinguished from that violent
closure of the eye which is found with or without
some disorder of the fifth nerve, by the fact that it
is simply a quiet shutting of the lid, and a resistance
on attempting to lift it up with the fingers, and an
absolute incapacity for a time to raise it by the will.
If this were a paralytic feebleness, there would, of
course, be no difficulty in pushing up the eyelid with
the finger, but, as I have just stated, this cannot be
done without the exertion of a good deal of force.
I fancy that, even among women, this condition is
rare, as I do not remember seeing more than three
or four instances. I mention them as curiosities and
as cases which you may occasionally see. There is
also a paralytic ptosis which is common among
women, and which I hope you will not confound
with the malady with which we are now dealing.
The last example I have seen of spastic ptosis was in
the person of a lady, who came from the interior of
Pennsylvania, and who has since died of cancer of
the stomach. She was a person easily tired, emo-
tional, and low-spirited at the same time. She
suffered also from nasal catarrh, and had, like most
of these cases, no photophobia. During the winter
previous to her visit to me she began to have, with-

CHRONIC SPASMS. 135

out known cause, a closure of the lids. They would
remain closed for several hours at a time, and then
would open with probably as little cause as they
closed. I saw her twice before I obtained an oppor-
tunity to see this symptom. She then seemed to be
unable to raise the eyelid, and I could not lift it
without a considerable amount of effort. I treated
her for a long time, and in various ways, and she
had at different times tried galvanism and electricity
and many other forms of treatment. Section of the
supra-orbital nerve had been proposed to her by an
enterprising surgeon, but she got well apparently
unaided by physicians, and died, as I have said, four
years afterwards of malignant disease. Another
case was in a woman of great intelligence and re-
markable accomplishments who had, I think, injured
her brain by excessive devotion to study. She had
no disease of the eye proper, nor any organic malady,
nor could I say that she was a notably nervous wo-
man. She had, however, been from childhood a shy
person, subject to blush too easily, and at times ex-
cessively embarrassed by the presence of strangers.
The trouble of her eyes came on for the first time at
a watering-place. When going to dinner, and sitting
down, she observed that a great number of persons
were looking at her as a last arrival ; she mentioned
the fact to her husband, and was almost immediately
attacked by a violent closure of the' eye, and was
obliged to be led in this condition from the table.
When this had happened once, you may well imagine
that every repetition of the original cause brought
back a return of the disorder, until at last it was

136 DISEASES OF THE NERVOUS SYSTEM.

quite impossible for her to go to table in the room
with other people. You will see that in this case
emotion, and, after the establishment of the symp-
tom, the despotic control of an unpleasant memory
were competent to create and then to continue this
grave inconvenience. I succeeded in inducing her,
however, to make an effort to go to dinner, without
regard to what happened, and to face the slight
unpleasantness and the talk which her appearance
might create. Her courage was finally rewarded by
a cure, which was perfected, so to speak, by a long
absence in Europe, and constant exposure to the
very difficulties which had given rise to her first
attacks.

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CHOREA OF CHILDHOOD. 137

LECTURE VIII.

CHOREA OF CHILDHOOD.

Some years ago I was struck with the rarity of the
true chorea of childhood among negroes, of whom a
fair proportion applied for aid at my clinic. In the
hope of securing more full information as to this
question, I asked my friend, the late Professor Henry,
of the Smithsonian Institution, to distribute in the
Southern States a circular, asking the following
questions :

1. As to the frequency of chorea in white children.

•2. As to its relative prevalence in localities.

3. As to its relative frequency in black children
of pure breed.

4. As to its frequency in mulattoes.

5. As to the season of greatest frequency of attacks.
This circular was sent, for the most part, to the

meteorological and other observers, who were cor-
respondents of the Smithsonian, and through them
to their friends. It reached thus a very intelligent
class, and fell into the hands of secretaries of State
and county medical societies, who were at much
pains to give me the collective experience of large
numbers of practitioners.

Had all, or nearly all, of my circulars been an-
swered, I could have quite fairly mapped out the

12*

138 DISEASES OF THE NERVOUS SYSTEM.

relative prevalency of chorea as to States. As it
was, my replies gave me the experience of two hun-
dred and ten physicians scattered through the towns
and rural districts of the South and Southwest. The
information thus obtained is very interesting, and,
however incomplete it may be, is too curious to be
laid aside. In the hope, therefore, that it may
awaken ampler and more exact research, I have
ventured to analyze it. JSTo one can feel more fully
than I how much it lacks of being perfect as evi-
dence, or how largely it is open to criticism on
account of the fallacies which are apt to pervade
information thus obtained.

The points w^ith which I shall deal will be :

The relation of the chorea of childhood —

To season and meteorological conditions.

To climate.

To locality, town or country.

To race.

Forms of chorea.

Relation to season. — It became clear, many years
ago, to every one who followed my clinics, that as
the cold of ,winter faded away, and the changeful
weather of March and April prevailed, cases of
chorea became frequent. This continued to be the
case until, with the w^armer season, the number fell
away, remaining then at about the same ratio through
the autumn and winter months.

These facts were so striking that at my desire Dr.
Gerhard collated all the available cases from the
note-books of the Infirmary for [N'ervous Diseases, in
order to arrive at an accurate determination of this

CHOREA OF CHILDHOOD. 139

point in the natural history of the disease. Soon
after, Dr. Mills published a like summary of cases
from the clinic books of the University of Pennsyl-
vania ; and within a few days Dr. Morris Lewis has
kindly brought together all of our own cases which
have presented themselves since the date of Dr.
Gerhard's paper, with additions from my private
note-books. This experience thus covers all classes
of society.

Dr. Gerhard found that my clinic and note-books
of private cases gave for the time of attacks of
sixty-eight cases of chorea, thirty-nine in the spring
months, ten in the summer, seven in the autumn,
and twelve in the winter. This result was suffi-
ciently striking, but was incomplete, because the
months of attacks were not indicated. The subject
seemed to me to promise interest enough to repay a
more exact study, and for this purpose an effort has
been made to relate the attack to months instead
of seasons, and to examine into the conditions of
weather which are to be found in periods of the
greatest and least frequency of chorea. For the
intelligent study here made of this difficult subject
I am largely indebted to the skilful industry of Dr.
Morris J. Lewis.

A few years ago no such study would have been
possible, but, the resources of the Weather Bureau
having been put at my disposal, I have found no
obstacle, save in the changes of the method of nota-
tion in its tables which have been made from time
to time,

140 DISEASES OF THE NERVOUS SYSTEM.

EXPLANATION OF TABLE I.

Line 1. Interpreted by using column of figures 0 to 80 ; is
intended to represent the mean relative humidity^ i. e.,
the mean per cent., and not the 7nean actual amount, of
the moisture which could be held in solution at the mean
temferature of each month ; the amount representing com-
plete saturation being indicated as 100 — the mean for the
month being obtained from the daily mean relative hu-
midity.

Line 2. Interpreted by using the column of figures 29.70 to
30.30 ; is intended to represent the ynean harometric read-
ings for each month.

Line 3. Interpreted by using the column of figures 0 to 80 ; is
intended to represent the m^ean thermo'tnetinc readings for
each month. (Fahrenheit scale.)

Line 4. Interpreted by using the column of figures 0 to 80 ; is
intended to represent the actual rainfall or melted snow in
inches for each month.

Line 5. Interpreted by using column of figures 0 to 80 ; is
intended to represent the tnonihs of onset of 170 separate
attacks of chorea.

Line 6. Interpreted by using column of figures 10 to 20 ; is
intended to represent the ynean daily range of temperature
for each month. This is obtained by subtracting the mean
of the minimum temperatures, of each month, from the
mean of the maximum temperatures of the same, and is an
indication of the variableness of the difi'erent months.

EXPLANATION OF TABLE II.

This table is merely a mean of the five years 1876-80, and is
interpreted in the same manner as Table I,

CHOREA OF CHILDHOOD. 141

EXPLANATION OF TABLE III.

Line 1. Is intended to represent the actual number of days on
which rain or snow fell in the different months of the years
1876-80.

Line 2. Is intended to represent the actual number of cloudy
days during the same period — the cloudy days being de-
termined by the following rule: " In determining whether
a day is clear, fair, or cloudy, its character will be deter-
mined by taking the sum of the entire number of fourths
of clouds, observed at 7 a. m., 2 p. m., and 9 p. m. A
clear day will be one in which the sum of observed fourths
is 3, or less than 3 ; a fair day, one in which the sum is
from 4 to 8 inclusive ; and a cloudy day, one in which the
sum is from 9 to 12 inclusive."

Line 3. As in Table II. ; is intended to represent the months of
onset of 170 separate attacks of chorea.

EXPLANATION OF TABLE TV.

Line 1. Is intended to represent the number of storm centres
passing within 750 miles of Philadelphia during the years
1878-80.

Line 2. Is intended to represent the number of storm centres
passing within 400 miles of Philadelphia (1878-80).

Line 3. Is intended to represent the months of onset of 87 sepa-
rate attacks of chorea (1878-80).

142 DISEASES OF THE NERVOUS SYSTEM.

Remarks and conclusions, — In drawing conclusions
from these tables, it must be remembered that, while
the meteorological portion is complete as far as car-
ried out, the number of attacks of chorea represented
is hy no means the complete number occurring in
Philadelphia during the fiYQ years under considera-
tion, but is merely a list of as many separate attacks
as could be collected, where the month and year of
onset were known without doubt.

In glancing at Table II. it is seen that the chorea
line (5) suddenly rises to a very high point in March,
this month having 35 attacks, or 20.58 per cent, of
the whole number ; the line then falls suddenly in
April, then rises slightly during the summer, to fall
again and reach its minimum in October, viz. : 6
attacks, or 3.52 per cent.; after this a very slight
rise occurs. In comparing this line with the line of
mean temperature alone (line 3) nothing especial is
seen, the same temperature in the autumn, as in the
spring, not being accompanied by an increase of the
disease ; nor is much light thrown on the subject in
comparing it with either the line of the mean relative
humidity (line 1), or w^ith that of the mean barometer
(line 2), except that there appears to be an increase
of chorea with a fall in the mean relative humidity
and barometric tracings, and vice versa. This can
also be seen in Table I., but not as plainly as in
Table II.

It has been stated that the disease is most preva-
lent during moist, cold weather; but this assertion
does not appear to be sustained by Table 11. , where
it is seen by comparing the lines 1 and 3 that Janu-

CHOREA OF CHILDHOOD. 143

ary, February, and December have a much lower
mean temperature, and a much higher mean relative
humidity than March, and yet these months have but
a small proportion of attacks.

l^othing of any apparent importance can be
gleaned by comparing the mean daily range of
temperature (line 6) with the chorea line.

In comparing the amount of rainfall and melted
snow per month (line 4, Table II.), with the chorea
line, there appears to be a slight coincidence, the
lines rising and falling together, except in May and
June, although the amount of rainfall is not propor-
tionate to the number of attacks. In looking at
Table III., it is seen that the line representing the
actual number of cloudy days (line 2) bears a much
closer resemblance to the chorea line than does that
of the actual amount of rain and snow (line 4,
Table II.). In July and August there appears to be
a discrepancy between the two, but in other respects
the resemblance is marked; the maximum attacks
of chorea, occurring in March, coinciding exactly
with the greatest number of cloudy days, and the
minimum, in October, coinciding with the minimum
number of the latter. The increase in the number
of cloudy days in J^ovember does not have a propor-
tionate number of attacks of chorea, although a slight
rise is perceptible.

Allowance must be made here for the method of
computing the cloudy days, as the rule previously
stated is not without its objections; for by this it
may rain, or there may be a thunderstorm on a clear
or fair day. The line representing the number of

144 DISEASES OF THE NERVOUS SYSTEM.

days upon which rain or snow fell (line 1, Tahle III.)
also resembles, in some respects, the chorea line.
This point will be referred to further on, after a study
of Table lY.

Line 1 of this table represents the number of storm
centres that have passed within a circle, whose radius
is 750 miles, draw^n round Philadelphia as a centre,
during 1878-80 inclusive. The two previous years
were omitted, as the storm records were not avail-
able. It was originally intended to construct a table
showing the number of storm centres that passed
within circles of varying radii; but as it w^as seen
that the resemblance between the storm and chorea
lines increased as the circles increased in size until
the largest with 750 miles radius was reached, it was
concluded to simplify the table by only tracing the
lines that represent the number of storm centres
passing within the circles of 750 and 400 miles radii
respectively; the latter line (2, Table lY.) being
inserted to corroborate the statement just made.

The reason of the resemblances between some of
the lines in Tables 11. and III. now becomes more
apparent, as they may be considered as component
parts of a storm, or as some of the factors of a storm,
so that a partial resemblance between them might
reasonably be expected. A conclusion which it seems
justifiable to draw from the foregoing study is, that
no single factor of a storm explains satisfactorily the
rise and fall of the chorea line, but it is where these
are taken collectively, as in the storm line, that the
greatest resemblance is seen.

It is worthy of note here that the chorea line of

CHOREA OF CHILDHOOD. 145

Table lY. resembles, in all its important features, the
chorea line of Table III., although there are 83 fewer
attacks included in it, so that it is reasonable to sup-
pose, if a larger number of attacks could be collected,
the resulting line would resemble those depicted in
the tables.

It appears that the area over which a storm has its
influence is strikingly alike in chorea and in neu-
ralgia, as proved by my former studies in the case of
Captain Catlin.'

It will be seen with what extreme caution we have
ventured to draw conclusions from the elaborate
study here made. It is at all events valuable as a
step in a good direction.

The facts which come out here so clearlj^ as to the
time of choreal attacks and their relation to storm
states would seem to indicate the further need for a
yet more refined and careful study of other points.
It were most desirable in future to set apart the
cases of chorea from fright and to study alone those
cases in which rheumatism accompanied or preceded
this disease, while it would be also most interesting
to learn how far the curve of acute inflammatory
rheumatism would compare with that of choreal
frequency.

It is, of course, probable that other factors than
conditions of weather may have a share in multiply-
ing attacks. One of these is certainly the influence

1 Am. Journ. Med. Sci., April, 1877. The Kelations of Pain to
Weather; and in the Transactions of the Philadelphia College of
Physicians, vol. vi., 1883. A more complete study covering eleven
years.

13

146 DISEASES OF THE NERVOUS SYSTEM.

of mental labor, I know of many cases which get
well when they cease to study, and relapse at every
new effort to do school- work. With us the public
schools have their most important examination in
June, when promotions are made and class rank de-
termined. The pressure on the children is often
considerable, and may have its share in the rise of
the chorea line in early summer.

It is interesting, as we pass from this subject, to
pause a moment in order to contrast with chorea, an-
other neural malady as regards their meteorological
factors.

Some time ago my colleague, Dr. Wharton Sink-
ler, showed that the paralysis of childhood is most
common in hot weather. He has now, at my request,
made out the curves of relative monthly frequency
of this disease as seen at our clinics since 1872, and
has added the curve of temperature. (See Table Y.)

The gradual rise to a maximum in August sug-
gests disastrous preparation by the weather of July,
our month of greatest heat ; and the minimum
reached in winter is certainly a fact which no pre-
vious theory of this disease could have prepared us
to suspect or anticipate.

Recurrence of Chorea. — The tendency of chorea to
recur is mentioned by several authors, and especially
by See. He speaks in one case of six, and in an-
other of seven returns ; and, what is most interest-
ing, he fixes on the autumn as the time of relapses,
as well as of the initial outbreaks, and thinks that
each successive attack is apt to be lighter than the
last, which has certainly not held good in my own

CHOREA OF CHILDHOOD. 147

experience. The French authors who mention any
time for occurrence or recurrence of this malady all
follow See's statement. According to him, the six
autumn and winter months furnish three-fifths of all
the choreas. This he attributes to the joint action
of cold and moisture, which seem to him the most
important factors, but which, as our tables show,
does certainly not hold good as regards this country
and latitude.

Dr. Gerhard's paper mentioned the facts observed
in this direction at my clinic, and in my private prac-
tice. Out of 80 cases, 25 had been attacked before.
Of the 25 cases, 14 had thus had chorea three times ;
8 had had it twice ; and 3 had experienced it four
times. Of the 25, nineteen recurred in the spring.

My later experience has given me cases of chorea
which have recurred in a yet more remarkable man-
ner. One young girl had chorea for four years either
in March or April; then once in February; and then
for two years in May. In another case the disease
broke out in a lad £et, twelve, and recurred every
spring for three years. In a third case, the disease
began in a girl of seven, and missing one year per-
sisted until she was thirteen, when it ceased to appear.
The attacks began usually in March or April.

I never knew a case to recur thus pertinaciously
in the autumn, although sometimes, in this latitude,
vernal attacks get well in summer, and recur in au-
tumn. The same holds good of winter chorea. If
cured, there is a positive tendency to break out in
the spring.

Dr. Morris J. Lewis's table of my own clinics gives

148 DISEASES OF THE NERVOUS SYSTEM.

this result as to repetitions of attacks : 126 cases,
representing 185 attacks.

Since I have been well aware of these facts, I have
been accustomed to warn parents of the tendency of
chorea to recur, and have always given careful in-
struction as to the general treatment of the child in
winter, and have always given arsenic as the spring
began. I have in this way broken up, in many cases,
the habit of vernal recurrence of chorea.

How far such facts hold good of other latitudes
than this I cannot yet say; bat I gather from many
of the letters of answer I received from our warmer
States, that the onsets of this disease are probably
more common in winter than with us. I have no
accurate numbers wherewith to settle the question.
It would be very interesting to know^ what law of
occurrence and recurrence chorea follows in Great
Britain,

Relations of Chorea to Climate. Locality. — After I
had determined the factor which I have here illus-
trated, I became somewhat interested in the question
of climate as related to this disease, and was soon
struck with the slight information on this subject to
be found in the books. Yon Ziemssen says that
Hirsch has now authoritatively contradicted Rufz's
statement of the rarity of this disease in the warm
zones both in black and white. Its relative fre-
quency is hard to judge of, because there is little or
no death-rate, and because cases are sometimes noted
as deaths from chorea, when they were due to other
maladies. Hence the only evidence is the statement
of physicians in active practice.

CHOKEA OF CHILDHOOD. 149

If I consider this, I should conclude from the
answers to mj questions, that warmth does not nu-
merically lessen it, as in fact my tables show. It
appears to exist in all of the larger cities all over
our Southern States, and also quite freely in Cuba.
Dr. Finley, of Havana, and Drs. Landetta and De
Castro, formerly of that city, report it as common
enough, especially among girls at the approach of
puberty. I hear like accounts from Lisbon and from
the great cities of South America. In a few cases
Southern physicians write me that it is rare even in
large towns, but when they add the number of cases
they have seen, it is usually clear that they have met
with quite as much of this disease as it is common
to encounter at the ITorth. The facts already pointed
out, which show clearly enough that chorea is seen
most in the spring and early summer, might very
well prepare us to find least of it in such localities
as the Bermudas, where the temperatures vary so
little throughout the year; but as to this I have no
information.

There is another factor in the case, and an impor-
tant one. It comes clearly out in the answers I re-
ceived. Chorea is a disorder engendered in some
way by the evil influences which are found wherever
men live crowded together in masses. It is essen-
tially a disease of cities. The larger cities, both in
the north and south, furnish it, as I should judge, in
much the same proportion. There is less in the
smaller places, and in country practice, north and
south, it is an exceptionally rare disease. Physicians
who have been twenty to forty years in rural prac-

13*

150 DISEASES OF THE NERVOUS SYSTEM.

tice, sometimes cannot recall a case, and yet, as we
know, rare cases are usually the best remembered.
Among one hundred letters, were twenty represent-
ing— and it is no bad way to put it — over three hun-
dred years of practice by men who have never seen
a case of chorea.

I should at least have expected to find, that, in
highly malarious countries, where, as we know, the
endemic influence tells severely on the health of all
ages, this lowering cause would be competent to do
what some combination of atmospheric causes en-
ables the spring and summer months to do — awaken
chorea. There is, however, no evidence to favor the
view that chorea can have a malarial origin, except
that here, with us, it arises in spring with as much
certainty as ague. But there is also some direct
evidence to show that there may even be something
hostile in malaria to chorea — a point which I make
with considerable doubt. It would seem, however,
that, in localities where malarious plains are bounded
by wholesome hills — as a most excellent observer. Dr.
Ellis, of Elkton, declared, and some other physicians
also — the chorea which they met with arose on the
hills, and not on the plains. To this I should add,
that, in certain of the most malarious regions of the
South, chorea is a nearly unknown malady.

It w^ould naturally follow upon what I have said,
that the disease itself would be found to increase
numerically in cities in direct proportion to their
growth. Of the increase of a rarely mortal disorder
we can, however, have no just conception, and the
deaths reported as due to chorea must, as I have

CHOREA OF CHILDHOOD. 151

said, be regarded with a certain amount of suspicion,
and this remark will especially apply to years long
past when there was far less accuracy of discrimina-
tion as to the causes of death from neural maladies.

The slightest study of the vital statistics of our
own cities will show how just is this criticism. In
Chicago from 1851 until 1866 there is no report of a
death by chorea at any age. Then in 1866 there is
one, a girl of 15 years, and then none to 1869, where
my statistics fail me. The population had mean-
while increased from 38,000 to 252,000.

In Philadelphia, between 1807 and 1881, chorea is
given as the cause of death in 64 persons, of whom
38 are said to have been under 20 years, and 26 over
that period of life. In this list are many over fifty
and many under two years, so that there were prob-
ably in these two sets a fair proportion of imperfect
diagnoses.

Race. — Although aware of the insufficiency of the
material on my hands to answer thoroughly this
question, I have felt unwilling not to use the letters
which so many gentlemen have been at great pains
to write me. I have, however, hesitated the more
because the tentative opinion on this question which
I reached quite early, has been criticised by very
able Southern physicians as not in accordance with
the facts they themselves had observed.

Let me admit, to begin, that in these letters there
may be many errors ; that rare cases may be for-
gotten ; that the negro often fails to call on a doctor
for even serious maladies; and, granting these
sources of distrust of my statistics, I do not see how

152 DISEASES OF THE NERVOUS SYSTEM.

we can fail to conclude as I have done, not that the
negro is insusceptible of having chorea, but that in
the black race it is far more rare than in the white.

Of sixty physicians who replied at length — some
lived in cities or towns, some in the country — twenty-
seven speak of chorea as rare in the white ; all of the
rest give the number, or an approach to the number,
of white cases they can recall. One has seen an epi-
demic outbreak of chorea. Of these sixty, forty-nine
have never seen chorea in the black ; the rest who
write speak of it as rare, or mention having seen
single cases. I should add that many of the exam-
ples spoken of were women, but exactly of what ages
is rarely stated.

Even this curious correspondence of view does
not, however, impress me so much as the character
of the writers of some of the letters and the extent
of inquiry which they have made. It may be well
worth while to analyze portions of this evidence.

Dr. B. De Landetta says, as regards Cuba, and
two others indorse his opinion : " I have never seen
chorea in the negro, which is strange, because it is
rather frequent in Cuba among white girls at puberty,
and because rheumatism is common in the negro."
Dr. Ch. Finley, of Havana, thinks chorea rare among
whites; but, despite his appeal to the Havanese
Academy of Medicine and the publication of the
questions in its journal, but one case of chorea in
the black could be heard of.

Among the letters are several from physicians who
had been large owners of slaves, and had also had
extensive plantation practice. One, Dr. Ashe, of

CHOEEA OF CHILDHOOD. 163

Alabama, having seen in all seven white cases, never
saw a case in the negro.

Dr. Benj. Lee writes that in a year of service in
the Hospital of the Home for Colored Children, ^ew
York, he saw a case of chorea in a mulatto girl aet.
15 end fatally, but has never seen it in the pure
black. Dr, Kollock writes me from Cheraw, S. C,
that he has seen in twenty-iive years of large practice
some twelve cases in the white and two in the negro
of pure breed. Three physicians write me from
Louisburg, I^. C, that one of them in thirty-six years
of practice recalls six or seven cases and one death
in whites. Two others have seen a few white cases,
and none of the three any black cases. Prof. J. L.
Cabell recalls but ^ve cases in the white, and has
seen none in the black. Prof. Bemiss, of 'New
Orleans, has seen cases both in white and black, and
does not feel sure as to this question. Dr. Ellis, of
Elkton, Md., a most competent observer, has ob-
tained, by careful inquiry, knowledge of thirty cases
in the white in ten years, and of two in black or
colored children. Dr. Michel, Montgomery, Ala.,
writes me that no one of the thirty members of their
County Society ever saw a case in the pure negro.
The disease is seen in whites. The secretary of the
Medical Society of Columbia, S. C, from corre-
spondence in the State and from the debate on this
subject in the Society, was unable to discover a case
of chorea in the negro.

Dr. Peyre Porcher, having put this question to
thirteen members of the Charleston, S. C, Medical
Society, received for answer that the disease is not
common among whites, and that no one of the num-

154 DISEASES OF THE NERVOUS SYSTEM.

ber had seen a case in the negro, and to this, Prof.
E. Gedding's adds testimon^^ to the same effect. Dr.
Laurance, of Hot Springs, Ark., says chorea is found
very rarely among negroes, more often among mu-
lattoes, but is not a common disease where he has
lived in the South. The general evidence in Vir-
ginia is very much to this effect, but in Richmond it
is clearly less infrequent, both in white and black or
colored, than elsewhere in the State.

On the other hand, many ph^^sicians in Virginia
state that it is as common in one race as in the other,
and Dr. Landon Edwards, of Richmond, after a care-
ful inquiry, reached the conclusion that the negro
has no immunity.

It seems to me, however, that as the matter stands,
the weight of evidence is in favor of the opinion that
the black is less liable to chorea than is the white.

Varieties of Chorea. — I pointed out some years ago,
that there exist at least three groups or species, in
the genus chorea of childhood. The significance of
the distinctions is not as yet clear to me, but I am
inclined to think that they may indicate a differ-
entiation in the anatomical sites of the central dis-
turbances which give rise to this disorder. As they
are not yet adopted in the books or confirmed by the
researches of others, I shall venture here to restate
briefly my views so as sufiiciently to illustrate the
peculiarities I have seen.

Group First. — The common type; awkwardness
and incoordination of voluntary movement, followed
soon or late by automatic or unwilled clonic spasms
of various parts.

CHOREA OF CHILDHOOD. 155

Group Second. — The disease never gets beyond the
first stage of incoordination. Just as in some scle-
roses of the cord there is no tremor save during
volitional acts, so here the irregular motions only
occur during willed actions.

Group Third is, I think, the most unusual type,
but I see occasional cases every spring. In this
there are constant automatic, irregular, clonic spasms
usually of the hands, but during volitional acts these
entirely vanish, and the most complicated acts are
well performed and without obvious incoordination.
In other cases voluntary motion merely lessens the
spasmodic activity, but does not abolish it. It is
necessary to illustrate only this third group.

T. C, get. 14, female, applied at my clinic in May,
1879. She was a florid, healthy looking descendant
of healthy people, but had one brother who was epi-
leptic. In March, 1878, she was attacked rather
suddenly with clonic spasms of both hands. These
parts were in incessant movement during the waking
hours, and until she attempted some acts of volition.
Then, and during the movement in question, they
were entirely free from all appearance of incoordina-
tion. She could write, sew, lift a glass of w^ater, or
do any other act involving complex motion without
the least tremor, but in a moment after it w^as done,
the fingers would again resume their spasmodic
activity.

I have seen a number of these cases. They are
distinctly choreal, and yield to such treatment as is
of value in that disease, but they difter plainly enough
from the ordinary type of chorea.

156 DISEASES OF THE NERVOUS SYSTEM.

LECTURE IX.

HABIT CHOKEA.

I HAVE over and over in my clinics called attention
to a disorder of childhood which is the source of
some anxiety and more annoyance both to parents
and physicians. This trouble I venture here to label
Habit Chorea, and for reasons which, I think, are
good and which will appear in full as we consider
the cases.

Over and over some anxious mother will ask you
to notice her child on account of some little trick or
gesture in which the child indulges. Then you will
see that it is w^inking rapidly, or pursing up the
mouth or drawing it to one side, or, perhaps, that
the brow is lifted at intervals or a shoulder shrugged,
or some forward movement of the jaw or head is
repeated over and over at varying intervals.

These acts occur usually in children of either sex,
but I think most often in girls from 7 to 14 years of
age. In many cases the single grimace or motion is
repeated for months and then disappears, and, if this
were all, I should hardlj^ think it worth while to label
so trivial a disturbance of health ; but in other cases
the first habit is lost by and by, and another takes its
place, so that the variety and obstinacy of the habits
become troublesome and even cause alarm; or, worse

HABIT CHOREA. 157

still, tlie little patient has a large repertory of these
performances, and will execute a remarkable variety
in one day. Usually, in such instances, there is some
one motion which is more violent or more frequent
than the others.

If you examine with care the history of these little
patients, you often find that there has been some fall
from the plane of health, and you will at once wish
to know w^herein the child's life and work and play
are not what they should be. Sometimes finding
nothing to blame, you will recall the fact that, in
the process of growth, children undergo cyclical
changes which are not permanent, and which in
turn may bring or take away tendencies to neurosal
disorders, so that you must not always expect to be
able to detect the causes of such disease.

If you analyze more closely the character of the
symptoms we are studying, you will find quite
enough to repay your care. You will observe, first,
that attention to the child increases the trouble, and
that any little failure in health has a like influence.
Then, if you see many such cases, you will observe
that these children are sometimes irritable or excit-
able, or exhibit clearly enough a condition of nerv-
ousness, being more emotional than is normal;
while, in a few instances, they lapse into well-pro-
nounced chorea of the ordinary type. In fact, this
disorder has a certain kinship to the latter aftection.
If you ask an intelligent child, who is thus diseased,
why it makes the grimaces, or repeats, at intervals,
some odd movement, you will learn that, while the
patient is able, in most instances, to restrain itself

14

158 DISEASES OF THE NERVOUS SYSTEM.

and control the exhibition of motor disorder, this
restraining power becomes increasingly difficult the
longer such effort lasts, and that a certain malaise
or discomfort results ; while to give way and let the
morbid impulse have full sway is attended with a
sense of comfort and relief.

Such is, in brief, all that T know about this small
malady ; although you w^ill, perhaps, comprehend it
better if I relate cases and point out, by illustrations,
the fact that its treatment should be very much that
which is needed in full-fledged chorea; another argu-
ment, if a slight one, in favor of the relationship of
the two disorders.

During the present month of N^ovember I saw M.
C. Gr., eet. 13, girl. I^ever a robust child ; at the age
of six she became, w^ithout known cause, nervous,
restless, and irritable; and was, for awhile, a bad
and uneasy sleeper. About this time she began to
have a slight hacking cough, which came and went;
was made worse by an attack of scarlet fever, and
still exists at times. It sounded like a cough which
was forced and voluntary. At nine or ten years,
the cough almost passed away, and was succeeded
by a sort of snuffling, during which she made the
usual grimace, always on the left side, and precisely
such a movement as accompanies snufiling. When-
ever she makes this contortion she pushes her cheek
up with the left hand. For a long while the cough
and the snuflBling act continued, the one or the other
being prominent for a time. She was scolded and
bribed into making great eftbrts to stop these morbid
acts, and more or less succeeded. The next summer

HABIT CHOREA. 159

she was taken to Saratoga, and tlie cough and snuffles
abated, but a new symptom arose. The mouth would
be opened wide, and as it closed both eyes shut, and
remained closed for a moment, or else this took place
without any opening of the mouth.

When I saw the child, all of these odd movements
were in full activity, but usually one of the three
was more frequent than the others. There was at
this time a good deal of dyspepsia, sluggish appetite,
and pain in the back low down, probably indicative
of the coming on of her menstrual flow, the ap-
proach of which was rendered probable by a rapid
development of her bust and pelvis. She had had
no worms, and no organic or functional disturb-
ances other than those I have mentioned. As she
is just now, for the first time, under treatment,
I can say nothing as yet of its success. Careful
and good diet, light gymnastics, no school, gentle
aperients, and full doses of arsenic constitute such
therapeutics as seemed to me reasonable. I ought
to add, that she does not seem in any degree mor-
tified at her own peculiarities, and this will be met
by some effort to make the matter appear to her as
rather disgraceful, and not to be mentioned — some-
thing, in fact, to be ashamed of. I shall be much
surprised if this combination of physical and moral
treatment fails us.

The next case I shall relate is quite as good a type.
This was a lad, aged fourteen, who was taken from
school a few months before on account of twitching
and nervousness. He had become also irritable and
capricious, and the grimaces, for which chiefly he

160 DISEASES OF THE NERVOUS SYSTEM.

was brought to mej^had increased, and had, indeed,
been increasing from the previous April, and until
he gave up school, late in July. It is, in fact,
usually safe in such cases as this, and in all choreal
troubles, to predict either a return or an increase
of the symptoms in the spring.

In this lad the twitches began with snapping of
the eyes, and this came and went, but was never
quite lost, but merely lessened when some new
symptom arose. The second form of trouble con-
sisted in a curious rolling of the head, difficult to
describe. This was bad enough, but quite suddenly,
within a few days, the face became more quiet, and
there arose a disorder of the abdominal muscles,
which were abruptly contracted at intervals. Over
this and over all these motions my patient had a
good deal of control. If he set himself to hold it
in check, this was possible so long as he steadily
attended to the task, but while it was easy to repress
it for fifteen minutes it was difficult after half an
hour, and increasingly more and more hard, until
by and by some slight lack of attention enabled the
act to recur, or else the sense of discomfort and
strain involved in these resolute acts of will power
became unendurable, and the lad abandoned the
effort. After a month or two of these movements,
the respiration was broken every few minutes by a
long drawn, abrupt inspiratory act. Still later the
head was affected, or rather the neck, with a
little, short, negative shake. The abdominal and
respiratory disorder gave way at last to shi*Qgging
of one shoulder, and then to this with a queer up-

HABIT CHOREA. 161

ward pull of the whole side. The worst attack
lasted but a few weeks, and was a sort of straighten-
ing up of the body. These varying conditions
endured for several years. At one time the boy
seemed well, then spring-time or any little malady,
especially indigestion, or much study and in-door
life, secured to reproduce the troubles in some shape
new or old. It was a slight grimace to-day, and in
a week or two it was a sudden action of the muscles
of the back or a shrug or a spasm of the muscles of
the belly. In no case did the hands or feet suffer,
and alwaj^s the disorderly act was distinctly con-
trollable by will; this repression was unpleasant,
and some relief was found in allowing the muscles
to have their way.

As the patient's eyes were plainly imperfect. Dr.
li^oj^es, of I^ew York, was so kind as to send me a
statement to the effect that the lad had, in the right
eye a slight mixed astigmatism, and in the left a
slight compound hypermetropic astigmatism. These
errors were really triJiing in amount. The eye mus-
cles showed some weakness. The eye-grounds were
healthy.

I had a long bout of treatment with this lad, whose
docility and good sense lent me every help.

He took at first a good deal of valerianate of zinc,
and had cold douches to the spine, and also arsenic
internally. Meanwhile he was taken from school and
set free in Virginia on the seacoast to ride, swim,
shoot, and fish. Notwithstanding these wholesome
aids, we got no further in the way of relief until we
began to use hypodermic injections of arsenic. For

14*

162 DISEASES OF THE NERVOUS SYSTEM.

this Fowler's solution without the lavender was used
thrice a week, in doses rising from two drops to
twelve, and as this heroic medication was followed by
rapid subsidence of the symptoms, it was continued
for nearly three months. A sea-voyage and residence
at an English school completed his cure, and then
we had also the favoring influence of approaching
puberty.

These cas€s, and I might readily add others, suffi-
ciently illustrate the varieties and the peculiarities of
the disorder to which, for reasons which must now be
plain enough, I have with some hesitation given the
name of Habit Chorea. The last case also defines suf-
ficiently well what the treatment ought to be.

DISORDERS OF SLEEP. 163

LECTURE X.

SOME mSORDEES OF SLEEP IN NEKVOUS OE
HYSTEEICAL PEESONS.

The man before us is a feeble ansemic creature,
who complains that be has become nervous, an ill
sleeper, and has lost weight. He is a coffin maker,
and looks as if he were artistically fitted for some
such ghastly labor. He has no organic malad}^, and
I only speak of him at all because one symptom of
his case is of sufficient interest to serve as a text.

He tells his story well, perhaps more dramatically
than I can, but with less brevity than I need just now.
When falling asleep he is conscious of something in-
definable, not describable, rising from his feet and
going up to the head. Usually he can move and thus
check the progress of the disorder; sometimes he can-
not, and then the attack results in a sense of some-
thing like a blow struck on his head. At first it
created terror, now he has become used to it, and is
no longer alarmed, although the expectation of it is
unpleasant, and apt to keep him awake.

This is a mild form of a very curious symptom — I
can hardly call it more — which is quite common
among hysterical women, more rare among men, and
which exists in a variety of forms, and is in such
persons at times a difficult symptom to deal with, and

164 DISEASES OF THE NERVOUS SYSTEM.

in certain cases the parent of a great deal of mischief.
In 1875, I published a brief paper^ on some of the
disorders of sleep, in which I described these phe-
nomena as follows :

" The trouble I shall describe is rarely found alone,
but makes a part of one of those groups of neurosal
symptoms which have no place in the books, and
which are apt to vary largely.

^'M. A., a prominent physician from the E^orthern
States, after a season of greatly excessive labor, be-
came rapidly anaemic and weak, and developed the
following symptoms : tingling, numbness, and heat of
the extremities — now here, now there — on the chest,
face, or scalp. At times, after much fatigue, islands
of vasal paresis, seen as slightly raised purple blotches
on the feet, are observed, and frequent waking up at
night, with numbness of either arm; feeble sleep, a
dull, occipital pain, which made him wish to hold the
part; singing in the head, referred now to the occiput,
now to the ears, but an inconstant symptom. He
was at last driven to consult me by the following
symptoms, which caused him the utmost alarm.

'^ When just falling asleep, he became conscious of
something like an aura passing up from his feet.
When it reached his head, he felt what he described
as an explosion. It was so violent and so loud, thaf
for a time, he could not satisfy himself that he was
not hurt. The sensation was that of a pistol-shot, or
as of a bursting of something, followed by a momen-
tary sense of deadly fear. This sense of an aura is, as
Brown-Sequard truly says, not confined to epilepsy."

1 Virginia Med. Monthly, Feb. 1876.

DISOKDEKS OF SLEEP. 165

I have now in my care, a very accomplished gen-
tleman, whose case is in almost every j-espect like that
just sketched, except that the numbness is never uni-
versal. The victim (Mr. Y.) is, in this instance, a
slight sensitive scholar, not overworked, but too
steadily worked, which may amount to the same
thing. In him, the numbness of the finger-ends came
on abruptly, but, as in the other case, there is no true
loss of tactile sense, and possibly, nay probably, the
feeling belongs to some condition of the lesser blood-
vessels of the part, and only secondarily to the nerves.

He feels, as he is falling asleep, a sense of something
about to happen, but no distinct ascending aura. If
he arouses himself in time, for which at the moment
he clearly comprehends the need, he can by turning
over relieve himself and break the chain of morbid
events. He can even watch, as it were, the coming
of the shock, and in some way know the moment be-
joud which he must not wait. The first patient de-
scribed as suffering in like fashion has also remarked
on this peculiarity. Mr. Y. has rarely the sense of a
pistol-shot or a blow on the head. "I have," he says,
'^ at the close of the attack, a noise in my head, which
is sometimes like the sound of a bell, which has been
struck once, and I have in my case listened as to a
bell, to the vibration coming and going at rhythmical
intervals, or else I hear a loud noise, which is most
like that of a guitar string, rudely struck, and which
breaks with a twang." The result is always, how-
ever, a sense of dread, but not such a death terror as
has Mr. A.

I have been told by other persons, that the}^ were

166 DISEASES OF THE NERVOUS SYSTEM.

liable, when going to sleep, to have sudden sounds,
faint usually, and rarely loud, but without feeling of
terror.

Since writing this account, I have seen a large
number of persons who suffer in like fashion from
some one of the various forms. The most of the
cases are women worn out, or tired out, and hysteri-
cal, whether strong and well nourished or not. In
sturdy men it is rare, unless they be excessive users
of tobacco.

The disorder in question I never saw in a man, ex-
cept in the border-land between walking and sleeping.
He may have the aura and then the subjective sensory
phenomenon, or the latter may come without warn-
ing ; but in hysteric females these attacks may arise
either at the moment of going to sleep, or during the
day at any time, and while fully awake. At times
they are slow in the march of their symptoms, and
may be checked by the patient if, what is rare, she
have enough of resolution ; but very often the aura
rises fast, too fast to allow of action or of emotion,
or else just slowly enough to give time for a sense of
fear, the full development of which requires a certain
amount of time.

The warning by an aura is common in women thus
attacked, and consists either in an indefinite sense of
something rising towards the brain from the feet or
hands, or both, or else it is a distinct tingling.

In a smaller number of cases the only warning
is an impending sensation of pure terror, which
increases until the sensory shock occurs. But as
regards all forms of the aura, or warning sensation, it

DISORDEKS OF SLEEP. 167

is found that, as a rule, the intensity of the emotion
weakens with repetition.

The aura is totally lost in the phenomena which
follow. These may be classified as follows :

1. In the sphere of general sensation : sense of a
blow, of shock on or in the head, of rending or
bursting.

2. In the auditory sphere : loud noise like an ex-
plosion.

3. In the visual sphere : flash of light.

4. In the olfactory sphere : sense of odor.

5. A combination of two or more of these sensory
manifestations.

6. More or less abrupt and general motion, the
ordinary outcome of any violent and sudden sensa-
tion.

It will repaj^ us to analyze somewhat more minutely
the peculiarities of these interesting attacks, since I
have usually found that they are not only sources of
alarm to patients, but of doubt and puzzle to their
medical attendants.

In the first group the final symptom is referred to
the head, and is a feeling of a blow, violent or light,
struck on the skull ; or it is a feeling so terrible as
to be described as something like an explosion, or a
pistol-shot, or more vaguely as a shock, something
undefinable and terrifying.

The auditory forms are described in their varieties
as a noise, an explosion, the sound of a bell, a boom-
ing sound— that of a guitar-string rudely struck.

The visual form is simply a flash of light, with or
without sense of noise.

168 DISEASES OF THE NEEVO-US SYSTEM.

The single case of an olfactory form of sensation
will be more fully described hereafter.

The affections of general sensation may exist with
auditory symptoms or not, since, when it is possible
to get a patient to evolve, out of the terror and con-
fusion of such attacks, an analj^sis, they usually men-
tion some disturbance of audition as going with the
sense of a blow.

In rare cases the patient is left with a momentary
vertigo; more often the start which announces the
sensory symptom ends the attack, so far as its imme-
diate phenomena are concerned, l^ot so, however,
its results in the emotional sphere. In some persons
it gives rise to great alarm, even after many repeti-
tions of attacks, and in these and others is apt to
leave the victim shaken and hysterical, or to be the
first of a series of hysterical symptoms, the end or
exact future of which no man can predict.

I would like now to illustrate some of these in-
teresting symptoms by cases, always asking you to
remember that in this lesson, as in some others, I am
picking out a single symptom for study, and that it
is not always the main feature.

The following case is told so well in the language
of the sufferer that I prefer to leave her account
almost unaltered. It is one of a few rare examples
in which the shocks occurred at times while awake
as well as during the state of sleep. A series of
severe mental and physical strains, and a slight sun-
stroke left my patient, a woman, now over fifty,
ansemic and reduced to the weight of seventj'-six
pounds, her height being ^ve feet three inches.

DISORDERS OF SLEEP. 169

Her eyes and ears were healthy, her womb normal.
There was no trouble of any internal organ, but there
was a loud soft hsemic murmur at the right side of
the base of the heart. Her sleep was good as a rule,
but was easily disturbed and insecure. She writes
thus : '' Some years ago, when thirty-nine years old,
after a long bout at nursing, sustained by quinine
and stimulants, I began to fail in health, and then
first became subject, whether asleep or awake, to a
sensation, which I can only describe as a wave going
through my head and threatening, as it seemed to
me, an unconsciousness which never came. If in
bed, I would start up, and if riding or walking would
clutch at some near object for fear of falling, yet I
cannot remember to have felt unstable. The fol-
lowing summer, after slight heat-stroke, and a new
exposure to severe fatigue of body and mind, I ex-
perienced, once only, a sensation like the explosion
of a pistol in my head. I hardly know how other-
wise to describe it. A few months later, I began to
have what I have always since called my shocks. A
peculiar something, which for want of a better name
I call electricity, starts from my head, chest, stomach,
or bowels, and seems to pervade me in a flash, then
comes the sense of shock in the head and an uncon-
trollable shriek. At first, it never came unless my
eyes were shut, but for one week, when I was most
highly nervous and sleepless, it would come if I was
startled by any sudden sound, and then I found that
for a short period I could cause it by touching a spot
over my stomach,

" Of late, these shocks are not always preceded by

15

170 DISEASES OF THE NERVOUS SYSTEM.

any length of warning, and are in the head alone.
They come mostly as I am going to sleep, and by
straining my eyes to keep them open, I can some-
times prevent the shocks altogether. I should say,
that there is often some queer sense of chilliness in
my head for an hour before the shocks, which is in
a general way a warning of what may come. I do not
like so to restrain them when the tendency is strong,
as I then have one or two during the night while
asleep, when they are very frightful to me. In some
cases there will be a succession of weak shocks, and
at last a strong one, when I shriek. After absence
from home and freedom from cares, I have been
exempt from these shocks for weeks or months."

This unhappy case I mention first, because of its
obstinacy. I have rarely seen the shocks thus per-
sistent, and I am sure that they will disappear when-
ever this woman becomes vigorous. iTeither is the
case quite typical, like one I have lately seen, and
which readily got well. It is valuable because the
shocks were so much the most prominent symptom.

Early this winter, Mrs. L., of Massachusetts, set. 45,
a ruddy, hale looking woman, five feet four, weight
156 pounds, came 'to me with this simple story: She
was well until her husband met, a year ago, with dis-
asters in business. Her anxiety about him, and the
worry attendant upon the management of a house-
hold with suddenly lessened means, were made worse
by the grave illness of her only child. She became
nervous under these influences, and began to suffer
from sounds which commonly cause no annoyance.
Then her sleep got to be imperfect, and she had a

DISORDERS OF SLEEP. 171

series of hysterical attacks — ^the usual spasms — tris-
mus, rigidity, hysteric coma, and the like, with a
slight but distinct and general lessening of acuity
of the sense of pain and that of touch. Finally these
phenomena passed away, and about this time she
became subject to the shocks I have spoken of.
These occun-ed either at the moment of going to
sleep, and w^hile quite conscious, or in the day-time,
and when wide awake.

The aura began in both feet, and ascended rapidly
to the head, sometimes being felt also in the hands
and arms. It was described as an air, and at times
as a faint tingling. It ended in a sudden sense of a
loud report, which caused her to seize her head with
both hands, and left her in a state of alarm and fee-
bleness, and with a brief but tumultuous throbbing
of the heart. The attacks took place irregularly,
once a week at first, and later at much longer inter-
vals. Their effect was disastrous, because they gave
rise to distressing nervousness, and sometimes to pro-
longed hysterical conditions, in which all her usual
hypersesthetic states were remarkably accentuated.

While she was under my care I saw a lady from
E"ew York who was a sufferer from a variety of ner-
vous symptoms, dependent in part on a split cervix
uteri and a lacerated perineum. These were sur-
gically relieved through operative means by Prof.
Goodell, but the after-treatment of the hysterical
conditions, hypersesthesia, sleeplessness, and intense
general nervousness was a slow process. The use
ot ether during the operation, which I have learned
somewhat to dread in grave hysteria, seemed to be

172 DISEASES OF THE NERVOUS SYSTEM.

the immediate parent for a time of an increase in all
her old symptoms, and of some new ones, among
which were the shocks.

The attacks came at any time except in sleep,
and were similar to those of Mrs. L., but less severe.
There was no aura, unless we can so call a feeling of
impending peril, which lasted a few seconds, and
ended in a sensation of a blow on the head. The
attacks ceased after a month, and have never re-
turned.

The next case I have to relate was more curious.
A girl, set. 18, was placed in my care some years
ago suffering from a slight unilateral hysterical paral-
ysis, with well-marked ansesthesia. She was far less
nervous than the woman 1 have described, and, in
fact, it is, I think, not i^are to find that women with
distinct hystero-palsies are, if we omit ovarian ten-
derness, fairly free from the various hypersesthesiee
w^hich constitute one of the groups of hysteric symp-
toms. She had, however, attacks when going to
sleep, in which she became conscious of a something
which seemed to ascend from the feet to the head.
If she could rouse herself, or turn over, the attack
terminated, and usually did not recur that night.
It sometimes happened, however, that she was not
able to act in time, or was clearly conscious that she
could not, in which case there was a wild fiash of
vivid red light, and she was at once seized with dis-
tressing nervousness, and sometimes with tremor.
I do not remember that the attacks ever took place
when awake, while it is as certain that they never
occurred during sleep.

DISORDERS OF SLEEP. 173

The next illustration of the double sensory dis-
charge giving rise to subjective feelings of sound and
light is valuable, because the account is given to me
by the sufferer, a medical officer of the United States
Army, R. M. O'E., set. 35, married, parents living,
both of gouty diathesis. He is, and always has been,
strictly temperate in all respects. Smokes in mod-
eration. When twelve years old, had a sharp attack
of intercostal rheumatism. In 1868 contracted ma-
larial fever, from which he has suffered more or less
ever since. In 1867 received a trifling gunshot
wound of right thigh. 1875 had concussion of the
brain, and some injury to back, resulting from a fall.
Was confined to bed for a week or ten days, and
walked with difficulty for some time after. Was
troubled w^ith vertigo for over a year. Has had no
other sicknesses nor injuries.

In June last, while sitting, lost consciousness ; did
not fall. On recovering saw objects surrounded
by a halo ; walked home with some difficulty, and
went to bed ; slept none that night, but occasionally
dozed, and was awakened by a sensation of falling,
or by a sudden noise, or by voices calling. Re-
mained in this condition for about two days ; could
arouse himself, but as soon as the effort relaxed
dozed, and had the feelings described. This con-
dition gradually wore off, leaving vertigo, appreci-
able muscular weakness (especially of the lower
extremities), a sense of constriction around the head,
w^akefulness, and want of appetite.

Late in June came to Philadelphia; consulted
Dr, Alison, who observed that one pupil was some-

15*

174 DISEASES OF THE NERVOUS SYSTEM.

what dilated. Subsequent ophthalmoscopic exami-
nation by Dr. Thomson showed that this condition
had passed away.

Early in August went to Oswego, and has passed
the time there and thereabout until a week ago.
Within the past month has had two or three severe
headaches, with pain over the left temple. These
have followed fatigue or excitement.

At present he can walk but a short distance
without growing very tired, then come vertigo,
seemingly confined to the posterior portion of the
head, and a condition of nervous exhaustion, lasting
some time. The same effects ensue upon mental
strain of any kind. He sleeps fairly well. The
feeling of constriction around the head is constant.
Appetite variable, but never very good ; bowels in-
clined to be costive; temper irritable; want of
capacity to think a subject out, or to decide any
question; has lost weight. ISTo organic trouble of
heart, lungs, or kidneys.

Since June last he has had several shocks, of an
explosive character, which appeared to be within
the cranium. They came at irregular intervals,
and without assignable cause. They have always
occurred just as he was falling asleep, and have
been preceded by no abnormal sensations. He is
awakened by what seems to be a loud explosion in
his head, accompanied by a flash of white and blind-
ing light. There is no pain with it, and except an
acceleration of the pulse there are no sequelae. The
noise thus heard is described as a rather low note,
accompanied with a feeling as if the head was sun-

DISORDERS OF SLEEP. 175

dered by the explosion. The attacks come and go,
but are always such as to make him dread the going
to sleep.

I have notes of a yet more singular case, which I
hesitate a little, and, perhaps, without due cause, to
class with these.

A woman, set. 40, and in good health, was hurt
during the tumult which followed the explosion of
the boiler of a steamboat. She was thrown against
the rail of the boat, striking her nose violently, and
then fell into the water, whence she was rescued
insensible. For several weeks she was very ill, and
recovering became the victim of acute hysteria, which
in a year passed away, leaving her feeble and emo-
tional. Her sense of smell was entirely lost from
the time of her accident; but she had at times a
subjective and very annoying impression of the
presence of an odor of brown soap.

When I saw her two years after her accident she
had, at long intervals, these symptoms. At any
time, awake or asleep, she became aware of some-
thing like a touch moving over her, usually about
the epigastrium. After a few moments she expe-
rienced a sense of shock in the head, usually at the
back of the head, and with it a remarkably distinct
sense of a strong odor, like that of bananas. It per-
sisted for, as she thought, a minute or more, and
then slowly faded awa^^

I have seen a number of these cases of sensory
shock, and I suspect that, wdien inquired into, we
shall find them less rare than might be supposed.
The instances I have related cover most of the varie-

176 DISEASES OF THE NERVOUS SYSTEM.

ties I have seen, and it only remains to say a few
Avords as to their clinical relationships, diagnosis,
and treatment.

The clinical relationships of these attacks are to
epileptic fits, and to those well-known, and, I may
say, normal phenomena of a sudden movement of
the body at the moment of going to sleep, or even
at other times, to which I shall presently refer
again.

The analysis of the shock attacks is simple. The
basis is hysterical excitability, or a hypersesthesia
from tobacco, or overwork with worry. The attack
itself is preceded in many cases by an aura of some
kind, which is the first sensory expression of the
coming disturbance. The aura is a phenomenon of
general sensation. Then follows a more or less
violent discharge from a centre of general sensation,
as of a blow or shock ; or from auditory centres, a
noise as of a bell, a guitar-twang, or an explosion; or
from visual centres, a flash of light ; or, perhaps, two
centres act at once; and there may be no aura, as in
many epilepsies.

The fact that these attacks do in some people take
place in the waking state, removes them from dream
phenomena, and from the domain of nightmares and
of night-terrors ; one form of which occurs in the
interval between sleep and waking, and presents
some analogies to these attacks of sense-shock.

In this form of night-terror, which is seen rarely,
but has often enough been described to me, the
sufferer is perfectly conscious of the coming on of a
nameless dread. Something precedes it in the way

DISORDERS OF SLEEP. 177

of a warning. He can, by an act of will, escape it by
motion, or he'may watch its onset. When it cul-
minates it is merely a state of insensate dread or
terror, without a felt cause, dreamed or other. This
seems to me, in the mental or mere emotional sphere,
to be closely akin to the sensory shocks.

As to diagnosis, I do not see how this disorder can
well be confused with anything else, unless with the
minor epilepsy, from which it ought to be easily
enough distinguished.

As to treatment there is not much to say, but
what there is to say is important and interesting.

As we are dealing chiefly with the nervous mala-
dies of women, the cases in which sensory shocks
are caused by tobacco and excess of brain-work do
not so immediately concern us here. I may, how-
ever, be permitted to say that in all symptoms
directly traceable to tobacco there are two remedies
available while the habit is being broken, strychnia
and alcoholic stimulus. It should be needless to say
that the man who orders the latter ought to have
some security that his patient will not construe his
orders too liberally. But this is a matter for a
doctor's conscience; and, at least, he may feel secure
that a little whiskey at bedtime will correct the evil
results of over-use of tobacco, and may be left off
as soon as the tobacco is much lessened. As to
strychnia no warning is needed ; and Dr. Landon B.
Edwards has pointed out, and with reason, that it is
the tonic most useful in the feebleness which comes
of abuse of tobacco — that pleasant wife and fatal
mistress.

178 DISEASES OF THE NERVOUS SYSTEM.

As to cases of sensory shock in women, the real
remedy lies in treatment of the co*nditions out of
which it grows. Of these, I have alread}^ said
enough, but there is one matter as to which, in the
nervous maladies of women, it is hardly possible to
say enough.

Perhaps I had better introduce what I wish to say
in this direction by a brief extract of a letter from a
woman who has suffered gravely from the shocks I
have described. She says: ^'I suffer, as you are
w^ell aware, from these shocks in the time between
sleep and wakefulness, and also in the day-time,
though rarely then. It did not seem to me at first
possible that I could in any way control these attacks
or save myself from their results. I found, how-
ever, that, as I had warning enough, I really could
do so. So I set myself every night to be resolute to
turn over or sit up if I had a warning; and every
day I said to myself, if I have the warning to-day, I
will not yield, but jump up and run about. To my
surprise, I found that by following out this determi-
nation with resoluteness I could break up most of
the attacks."

The treatment hinted at in this letter from a clever
woman is really valuable. It consists in instructing
the patient before going to sleep, and every day, to
keep in mind the need to break the attack by motion
and by an effort of will.

I do not know of any drug which is directly use-
ful in such cases of sensory shock as seem too grave
to await in patience the influence of general tonics.
The bromides are of value when used in very fall

DISORDERS OF SLEEP. 179

doses, such, indeed, as it is not well to employ
long; in the smaller doses in which they do good
in hysteria, they are, as regards this particular
symptom, valueless. Small doses of chloral or
morphia, used until the habit be broken, answer
well ; but still better is a general improvement in
health, and then, if the attacks persist, such exercise
as will insure natural fatigue great enough to make
it impossible to avoid sleep.

In the same paper on sleep to which I have already
alluded occurs some brief account of the motor dis-
charges which are so familiar to us all as taking
place just at the moment of deepening sleep.

What I pointed out then, and what I wish to re-
call attention to here, is that this normal symptom,
if I may be allowed so to call it, does sometimes rise
into the mischievous position of being the dominant
difficulty in a case on account of its interference
with sleep.

The symptom in question — while it rarely takes
place except in the interval between waking and
sleep, and never between sleep and waking — may
also arise during sleep itself, and cause abrupt dis-
turbance. I have seen it very troublesome in grow-
ing lads and in some overworked men; but it is rare
to Hnd it so strikingly developed as in the case of a
woman who consulted me to-day. This unfortunate
person was forty-three, the mother of several chil-
dren, and of late irregular in her menstruation.. I
was struck with the fact that her color was good,
but that she was curiously thin and very haggard.
She is well as to her digestion, but has too much

180 DISEASES OF THE NERVOUS SYSTEM.

wind, and finds eating hard work; otherwise she is
well in the day-time, and can read, sew, walk, or
drive, as pleases her. Once or twice she has had
long crying spells, without other cause than a sense
of the wretchedness of her condition. When bed-
time comes she goes with fear and reluctance to en-
counter sleep and the discomfort it brings to her.
Just as she begins to lose herself, an arm, a leg, or
the whole body suddenly moves with violence. As
she awakens, her hands and feet, or either alone,
twitch for a few moments. Then she settles herself
to sleep anew, only to repeat the same process, until
at last she sits up, crying hysterically, or, worn out,
falls into a slumber seemingly too sudden and pro-
found to allow of the phenomena I have described.
Her daughter, who came with her, described these
nights of sufiering as truly pitiable, and told me that
nothing had as yet seemed to afford the least relief.

Of late, Mrs. R. J. has been apt to wake up later
in the night with unilateral tingling, of which I shall
presently speak more fully.

You must, of course, consider this as an unusual
case; but it is just unusual cases which are apt to
puzzle young physicians; and to be able in such in-
stances as these to recognize the close kinship between
an almost natural phenomenon and its excessive de-
velopment into an annoying disorder, is not ouly
comforting to the patient but useful to the physician.

A good many hysterical women exhibit this symp-
tom; and in a few it becomes troublesome, either
by its repetitions, as in Mrs. R.'s case, or, what is
less common, from its severity. A quite ludicrous

DISORDERS OF SLEEP. 181

example of the latter I saw a few years ago. The
patient was one of those stout, ruddy w^omen, with
good ovaries, and uterus where it should be, and
yet hysterical to an exasperating degree. She
w^eighed over 200 pounds, and was unhappily sub-
ject to what she called "fish-flaps," which were really
remarkable, because her body would be thrown up
from the bed so high, and descend with such violence
owing to her weight, that it was not rare to find the
slats of the bed giving way. She grew" better as her
hysteria lessened, but is, I believe, still subject at
times to these unpleasant and undesired gymnastic
symptoms.

There is yet another and a very interesting sleep
symptom seen at times in some spinal maladies, and
in a variety of degrees in feeble and ansemic per-
sons; but far more common among women than
among men. I ventured some years ago, in speak-
ing of it, to call it "night palsy," or "nocturnal
hemiplegia." Since seeing more examples I perceive
that brachial monoplegia is its most common ex-
pression.

This curious symptom assumes one of two forms
— the one common, the other rare. In the more
usual cases the sleeper awakens with numbness, or
rather tingling and numbness, of one arm, or of a
leg only, which is infrequent, or the whole side, in-
cluding the face, and even the tongue, which is now
and then attacked alone. The disorder may be mere
tingling, or actual loss, or rather lessening of tactile
sensation ; but in any case it rapidly fades away, or
yields to a little friction. At first, when it is confined

16

182 DISEASES OF THE NERVOUS SYSTEM.

to the arm, the patient refers it to lying on the part ;
but this becomes an impossible explanation of the
hemiplegic examples.

As I have seen in a month three cases of this
rather interesting condition, it cannot be very rare.
It is significant, perhaps, that some persons who have
gotten pretty well of a hemiplegia of organic cause
are liable to awaken out of sleep with numbness and
lessened power of the side once palsied. It is re-
markable that in the case of Mrs. R. J., of which I
just now spoke, this same curious functional hemi-
plegia would at times occur on the same nights when
she suffered from motor discharges.

The less common form of night palsy is, perhaps,
also the more serious, but may be like the usual
examples, but an expression of hysteria or of the
exhaustion felt by an ill-nourished brain during the
long fast of the sleeping hours. In it the patient
exhibits a far more distinct loss of unilateral power,
which, however, lasts for an hour or more after
awaking, and may even become worse for a time in
place of at once improving.

I recall very well the case of Mrs. C. L., set. 27,
who, after profound blood losses in confinement,
nursed a child, with success, through several men-
strual periods. She then had an attack of nocturnal
hemiplegia, which became more grave during some
hours. She had after this several light attacks, and
twice well-marked brachial diplegia, which lasted
but a few hours. I should add, that there was no
renal trouble, and that she made a perfect recovery.
Among other milder forms of trouble, which at

DISOKDERS OF SLEEP 183

times haunt the sleep of nervous or hysterical fe-
males, are palpitation of the heart, vertigo, and a
certain failure of the respiratory centres, which is
met with also in grave shape in some cases of Du-
chenne's disease, or in any very feeble people, and
is, of course, not confined to women.

In locomotor ataxia, towards its paralytic stage,
this symptom is but an expression of a defect in the
medulla oblongata, and has twice in my knowledge
finally resulted in sudden death during sleep. In
weakly and hysterical people it means simply a tem-
porary failure of function, owing to imperfect nutri-
tion.

The centre remains competent so long as the will
is free, during the waking hours, to assist the auto-
matic activity of the ganglia, but when sleep leaves
the regular succession of respiratory acts to the un-
aided powers of defective nerve-cells, there sometimes
comes a moment of temporary incompetence, and
the patient wakes up gasping and alarmed.

The best remedy for these troubles is to be found
in general treatment, of which I have already said
enough, and in great care to supply nourishment
at bedtime, and if needful to repeat its use during
the night. Of course I take it for granted that every
care shall have been given to the state of the stomach
and bowels; and I may add, finally, that some pa-
tients suffer less, or not at all, if lying on one side
or the other, or on the back, the best position being
purely a matter of experiment.

184 DISEASES OF THE NERVOUS SYSTEM.

LECTURE XL

YASO-MOTOR AND EESPIRATORY DISORDERS IN
THE NERVOUS OR HYSTERICAL.

I HAVE over and over called attention in my clinics
to some of the many and curious vaso-motor disturb-
ances which we see in such great variety among
nervous women. From the heart to the capillaries
we are liable to meet with conditions of disorder,
which are sometimes almost as lasting as if they
owed their parentage to obvious and coarse structural
lesions. This indeed is a familiar fact which I have
had ample opportunity to verify both in my clinic
and in my private practice. 'No matter what be the
form of general nervousness or the variety of hys-
terical illustration, the nervous supply of the heart
or vessels, or both, almost never escapes from bear-
ing some part of the mischief, and only too often,
after everything else is well and the patient is afoot
and able to live as pleases her, she will still be re-
minded by something in connection with the blood-
supply and its channels, that they are almost the
last to regain the vigor and steadiness of health.

The first point to which I wish to ask your atten-
tion is the pulse. In the mass of hysterical women,
and especially in those we see here who are apt to be
feeble, and easily tired as well as liable to tears and

VASO -MOTOR DISORDERS. 185

to more distinct expressions of the hysteric tempera-
ment, the pulse is apt to be permanently rapid, that
is for months or years it may remain 20, 30, 60 pul-
sations to the minute above the normal number.
You may see this in a woman who is supine in bed,
and who for the time presents no startling evidence
of general disorder. I shall have presently to illus-
trate this fact by cases.

But besides the speed of the heart movement
these cases present also two other phenomena; their
hearts are irritable and prone to beat rapidly owing
to causes which are powerless to affect the less ex-
citable organ of the healthy. Then also with this
cause of being set going beyond their common rate
these hearts are apt to become irregular, and to seem
to tumble about in an alarming manner. The care-
ful study of these well-known peculiarities will very
well repay us. Therefore, before going further, we
will linger a little upon the questions connected with
the pulse-rate and rhythm of nervous or hysteric
women.

Out of half a dozen good cases I take two or three
to enable me to illustrate these points. After that
I shall point out some of the eccentric pulse symp-
toms, and then say a few words as to the mode of
dealing with the irritable heart of the nervous, either
when it is but a symptom, or when it rises into such
prominence as to be the dominant mischief.

There was last year in the Infirmary for I^ervous
Diseases, a lady from Virginia, who presented in a
typical form the cardiac states which I expect to find
in neurasthenic women, and especially in such as are

16*

186 DISEASES OF THE NEEVOUS SYSTEM.

both feeble and hysterical. She was 38 years old,
married but childless, and had been for some years
subject to hysterical attacks, which passing away left
her at last so feeble that she was unable to walk up
stairs without great exhaustion. She was five feet
one, weighed one hundred pounds, and was anaemic
and sallow. Her uterine functions were fairly good,
and she suffered no pain and had no distinct uterine
disease although both ovarian regions were tender,
and pressure upon them caused nausea and vertigo,
as well as other phenomena to which I shall presently
refer. Her digestion was good if she ate but little
at a time, and was not tired or excited.

Her heart, when she was lying down, was never
under 130 beats per minute. Any exertion raised
it 20 to 30 pulsations. The least excitement did the
same, but despite this irritability the rhythm was
always good, and I should add there was no affection
of the eyes or the thyroid gland. Pressure on the
ovarian region gave rise to sudden increase in the
number of heart beats, but pressure on the spine
almost anywhere had a like influence. She had tried
absolute rest for a week or two at a time, and had
taken a large amount of tonics and of digitalis.
Her temperature was curious, being in the mornings
97-97.5°, and in the late evening, 9 to 10 p. m., 100-
101.5°, although there was no pulmonary or other
visceral trouble. The evening pulse was usually a
few beats under that of the morning.

Electricity (induced current, slow interruptions)
used as a muscular exerciser, and also massage, ex-
cited her greatly, causing tremor, tearfulness, and a

VASO -MOTOR DISORDERS. 187

rapid increase in the pulse. Withal, the heart was
perfectly healthy as to its valves and its size.

I began her treatment by using various forms of
digitalis, but although she took enormous doses, I
never succeeded in making any impression on the
heart, and nsually this drug seriously disturbed diges-
tion. I found that frequent small feeding with rest
somewhat aided her, but although she was thus made
more comfortable there was no substantial gain, until
in despair I resorted to Carell's skimmed-milk treat-
ment. After three weeks of this I was able to repeat
the use of massage which I had been forced to aban-
don. From this time the improvement in flesh,
color, and self-control was notable. When she was
able to walk about after two months of rest, the
heart beat had fallen to 95° and was far less excitable,
and her temperature had become normal. It re-
quired, however, many months of care to make her
circulation quite natural, but within six months she
became fat (one hundred and thirty pounds), and
was able to complete her cure by a summer in the
mountains.

This was, of course, an extreme case of cardiac
nervousness, but it is no unfair type, and I need add
little to the description. Sometimes the tumultuous
action of the hysterical heart is the most distressing
and most upsetting of all the many symptoms of this
disorder, so very fertile in symptoms. We all know
how unpleasant and appalling even is the sense of
sudden and great irregular palpitation, and in the
nervous and hysteric this impression loses nothing
of its terror. You will meet with such women — -

188 DISEASES OF THE NERVOUS SYSTEM.

women whose hearts seem to become wildly irregu-
lar on the least provocation, or on none. Digestion
in these women causes it, and here I cannot too ear-
nestly insist that digestion, like some other functional
acts, may give rise to symptoms which are not of
necessity proofs that the function in question is im-
perfect or diseased. Ordinarily, if we have palpita-
tion of a healthy heart during digestion, that means
often enough that our patient is dyspeptic, but not
so in nervous and hj^sterical women. Digestion
naturally quickens the pulse, and in these people the
normal quickening passes into palpitation. That I
am correct as to this is shown in the same women
more rarely by the varied disturbances which follow
the most perfect performance of other normal func-
tional acts as simple as micturition or defecation. I
have seen patients in whom bowel movement always
produced irregular heart action, and I have now a
lady under my care who has, soon after passing water,
slight chilliness, twitching of the face, and extreme
palpitation of the heart. Yet, the act of urination
is, in this case, painless, and, in fact, absolutely
natural. You may regard all of this as of trifling
moment, but I have seen cases like these treated
with many drugs, and in a case similar to the last
one I have known a surgeon resort to dilatation of
the urethra. Bear in mind, therefore, that some-
times in nervous people the adimty of a normal function
is competent to cause distress in other organs or to aioaken
unusual symptoms.

The violence and suigularity of the pulse-signs in
true hysteria are beyond expression strange.

VASO-MOTOR DISORDERS. 189

I saw, very many years ago, a handsome girl, of
twenty, from Cincinnati, who had spells of apparent
death, if I may use such a term. One of these I had
the good fortune to see, and, indeed, to cause, for
having been warned that, to speak before her of cer-
tain things, was apt to cause the trouble, I unluckily
began to discuss with her the subject of a personal
peculiarity, from which I had been told she suffered.

It seemed that certain odors would, in her, bring
on hysterical attacks. You may recall a case here,
last week, of an aphonic girl, in whom musk would
do this. ISTow, my patient had at last become very
sensitive as to this as to other matters, and no one
near her ventured to talk about odors; since then it
seemed that the young lady was liable to suffer, as
if from the odors themselves. Of late the hystero-
epilepsy had given place to the " Death spells," as
her friends called them, and it was one of these I
provoked. She said to me, "I am going to have an
attack; feel my pulse. In a few minutes I shall be
dead." Her pulse, which just before was about 100,
was now racing, and quite countless; while the
irregularity and violence of the heart's action seemed
to me inconceivable. With the interest of an hys-
terical woman in her own performances, she said to
me, "N'ow watch it; you will be amazed." This
certainly was the case. Within a few minutes the
pulse began to fall in number, and, as well as I can
recall it, in some fifteen minutes was beating only
40. Then a beat would drop out here and there ;
the pulse meanwhile growing feebler, until at last I
could neither feel it, nor yet hear the heart. In

190 DISEASES OF THE NERVOUS SYSTEM.

this state of seeming death, white, still, without
breathing or perceptible circulation, this girl lay for
from two to four days. In this time there were
spells of a few minutes, during which the heart beat
again furiously and irregularly, as was also the case
when she revived.

Of course, emotion of any kind is, in these women,
able to disturb the heart rhythm and its number;
and while such persons are subjected to the contacts
of daily life, it is therefore hard to relieve them.

The oddities of hysterical cases are perceptible
enough in the way in which the heart-action seems,
at times, to disobey all apparent laws. I have seen
such persons^ whose hearts beat slower when they
rose, and faster when they were lying down. I have
now a patient, w^hose heart is quiet enough while she
is supine, but to lie on either side causes palpitation
and increased rapidity of pulse.

There are now in the Infirmary two cases of
great general nervousness with hysterical histories.
ISTeither has organic disease. The one has an aver-
age morning pulse of 100, and a night pulse of 75.
The other nearly reverses these numbers, but I have
been utterly unable to find a precise cause for these
peculiarities.

Apart from cardiac troubles and arterial throb-
bing, or in relation with them, are certain vaso-
motor disturbances which give rise to very distress-
ing, or, at least, to annoying troubles in this class
of sufferers.

Every hysterical vv^oman is liable to a certain w^ant
of tone in the surface-vessels w^hich gives rise to a

VASO-MOTOE DISORDERS. 191

group of disorders, owing to which we meet with
extreme states of pallor or of flushing which in some
cases aifect the extremities and in others are most
visible in the face. This want of steadiness in the
vessels of the skin belongs to some extent, and
naturally, to others than the class I speak of, and is
seen very well in certain healthy women of fair
complexion, and is also common in persons who are
liable to the congestive type of neuralgic headaches.
Watch one of these women, and if they have this
peculiarity in a high degree, it will come out under
the excitement g-nd embarrassment of clinical ques-
tionings You will then see the face flush, and the
flush by degrees break up into spots of red which
move slowly and have bounding margins of pale-
ness; and all this will be best seen on the neck and
cheeks and below the ears. At the same time the
hands and feet may become cold, and, at all events,
you will find that almost incurably cold feet are the
constant annoj^ance of these patients; and some-
times the cold feet are pale; and sometimes, in
graver hysterical cases with palsy or sensory defects,
they may be purplish ; and both appearances indi-
cate, as you know, defects of blood-supply, and both
lead to like results.

Another and very remarkable indication of the
acquired sensitiveness of the surface-vessels in cases
of the hemiplegia of hysteria is the well-known fact
that any moderate traumatic injury to the skin-
vessels gives rise to their instant contraction, so that
slight wounds which usually bleed do not do so in
them. I have seen this state of things in hysterical

192 DISEASES OF THE NERVOUS SYSTEM.

girls who were not suffering from analgesia, but in
most cases it is found over a half of the body affected
by some loss or lack of feeling of some kind. As
the feeling improves, the needle wound bleeds, and
whatever aids the one condition helps the other, so
that, when from the use of metals the phenomenon
of transferrence of the ansesthesia to the opposite
limb occurs, it is at once found that needle wounds
cease to bleed on the side attacked, and bleed on
that deserted by the disease. As I said in a former
lecture, I have myself been unfortunate in never yet
having been able to see the phenomenon of transfer.
I have several times seen metals laid on the anses-
thetic parts give rise to some partial return of feel-
ing and of bleeding from needle-pricks, but I have
seen caoutchouc and wood, and even sponge do the
same; and the effect of a blister and of the rhigo-
lene spray can be seen in a patient now in the wards.
I may add that dry cups and mustard have also
given me the same results. There may be indeed
some unsuspected relation between loss of sensation
and the bloodlessness of slight wounds, for in one,
at least, of those remarkable cases of total surface
anaesthesia to all forms of sensory impression, a
case of profound melancholia, although the loss of
feeling extended to the face and mouth, and was
certainly not hysterical, the surface was made to
bleed with the most extreme difficulty. The same
phenomenon of failure of pin-pricks to bleed has
been recently observed by me in a man with hemi-
ansestliesia of cerebral and organic cause. It seems
likely that cutaneous ischsemia is to be added to the

VASO-MOTOR DISORDERS. 193

list of symptoms which Charcot has pointed, oat as
common to hysteric hemi-palsies, with loss of pain-
sense, and the hemi-ansesthesia of more definite
cause. Since I was led to suspect that there is some
link of relation between ansesthesia and surface
failure to bleed, I have been on the lookout for a
case of nerve section in which to test the matter.
Two days ago Dr. R. J. Levis cut the sciatic and
crural nerves in a man who has a deep and incura-
ble ulcer of the left leg. The operation deprived
him of all sense below the middle calf, and I was
enabled, with Dr. Levis's permission, to examine
the case in his ward at the Pennsylvania Hospital.

All forms of sensation were extinct in the foot.
Using a very large needle, I left it in place some
time, or turned it about freely, but was unable to
cause a single drop of blood to flow from these re-
peated wounds. As I withdrew the needle, a small,
snow-white ring, slightly raised, formed around the
orifice, and seemed to be due to contraction of the
neighboring skin muscles. This most interesting
observation confirmed for me what already I had
seen some years ago in other and less extensive nerve
sections. I had, however, continued to doubt the
correctness of the former observations, which were
made in cases of division of ulnar or median trunks.-
It certainly seems as though the loss or lessening of
sensation were associated with the taking off from
the skin vessels of some inhibitory influence, thus
leaving them to contract with violence under the
influence of any irritating cause. All explanations
may admit of question, but as to the fact to be ex-

17

194 DISEASES OF THE NERVOUS SYSTEM.

plained, I think there can be no further doubt. I
hope that I have here said enough to direct attention
anew to this interesting phenomenon.

Temporary flushing or pallor of face is very apt to
accompany sudden and irregular heart action, and
to become and remain a distressing symptom. Why,
with a perturbed heart, one woman should have a
deadly paleness, and another a profound flush of face,
I cannot say, but both sets of conditions are familiar
to me. E'ow, as in such females the heart becomes
agitated, and the face red or white on the least
provocation, or on the mere expectation of it, you
can readily see what an annoyance it may become.

I saw last year a bright, intelligent E"ew England
girl, who, with much general nervousness, had also
a heart far too rapid, but besides its speed, if she
met a friend suddenly, or went into a drawing-room,
or was even spoken to unexpectedly, her heart be-
came irregular, and her face very pale. You may
readily imagine to how much misconception such a
disorder might give rise. The longer it lasted the
worse it became, and one pleasure or one duty after
another was given up in turn, because of the shame
to which every mildest emotion subjected her. After
long treatment she became well as to most of her
ailments, but had been a year in seeming health be-
fore her circulation reacquired the proper tone, and
she could again face, without fear, all the trials of
social life.

Flushing with tumultuous heart action is more
common, and is, I should say, more like an exag-
geration of a common functional event of health.

VASO-MOTOR DISORDERS. 195

Still, when it occurs habitually on the least emotion,
it is, like any such symptom, a source of most bitter
annoyance.

Unilateral, or strictly local flushing, is, I suspect,
a very rare affection, either in hysteria or elsewhere,
but, of course, the best examples are to be found in
hysteria.

Last year I was consulted by a lady, both of whose
legs were as red as blood in excess could make them,
and this state came on after many months of varied
hysteric troubles. Excepting an imperfect paraplegia
these had all passed away for the most part, but
whenever she sat up, her legs filled with blood and
looked as if they might burst. Unlike cases of ery-
thromelalgia there was no pain, and when the limbs
were elevated they slowly got back their color. Pin-
pricks bled easily, and there was no loss of feeling.
I watched this singular condition for some weeks,
every effort failing to relieve it, and finally, I may
add, that when it was let alone, and only the consti-
tutional state was looked after, the local paralysis of
vessels gradually got v/ell.

I have over and over seen this vasal paresis in the
hands of these women, and one distressing case of
intense and permanent redness of the face, which
took, at first, a unilateral form, and then attacked
the entire face in spells. These began at any time,
but chiefly in the morning hours. A spot of color
came anywhere on the face, went and came, and at
last others appeared. These coalesced after a time,
and the color deepening the face, scalp, ears, and
upper neck at last looked like those of a heavy

196 DISEASES OF THE NERVOUS SYSTEM.

drinker. There was no pain, or only a sense of un-
comfortable fulness and heat. The eye-ground did
not seem to share so fully in the vascular fulness,
but the depths of the ears did. Relief was obtained
by a spray of cool water, which did best at a tem-
perature of 50° to 60° F. If let alone, the redness
passed away slowly within three hours. At first,
and at times afterwards, the heart's action was dis-
turbed a little. I should add that very prolonged
use of digitaline seemed, with care of the general
health, to do the most towards the complete relief
of this unhappy patient.

The last case of hysterical vaso-motor manifesta-
tions which I shall quote was so amazing that if I
had not had the good fortune to see it over and over,
and to show it once to my friend Dr. William Y.
Keating, I might reasonably have hesitated to tax
the credulity of my hearers.

Some twenty years ago I attended a young mar-
ried woman, whose life was embittered by losses of
propert}^, and by the ill-treatment of her husband,
who finally deserted her. For a long period she ex-
hibited, at times, hysteric disorders in the forms of
spasms, rigors, hemipalsies, and at last, for a month
or two, moderate maniacal excitement. With favor-
ing circumstances she at last got well, and removing
to the West, was lost sight of until about ten years
ago, when I was called to see her at a hotel in Phil-
adelphia. At this time my patient was 35 years old,
was irregular as to her monthly flow, and had, as I
found, a womb tilted forward, but not diseased, and
no ovarian tenderness, or, at least, no tenderness of

VASO-MOTOR DISORDERS. 197

belly which was not the same everywhere. She was
rather pale, and very thin, and had a relaxed pendent
abdomen marked by the scars of four pregnancies.
I could find no disease of heart, lungs, or kidney.
She gave me this brief history : After some years of
ease and comfort, she had been led to risk her prop-
erty in a wild speculation which ruined her, and now
she was keeping a boarding house, in E'ew York,
and was doing well, or likely to do well, except for
the strange malady on account of which she came
to consult me. After her new misfortunes she had
some hysterical troubles, but these ceased to annoy
her, and she began to observe that at or about the
time of her menstrual flow, and afterwards at any
time, she was liable to have an enlargement of the
belly, which did not seem to her to be due to wdnd,
as with that form of swelling her previous experience
had made her but too fully acquainted. The trouble
became by degrees w^orse, and at last was so extreme
as to cause certain unpleasant feelings, and to subject
her to suspicions of being pregnant.

The swelling was certainly caused at times by
emotion. It began at any time, rarely at night.
Within a few hours the belly, in place of being
flaccid and pendent, w^as swollen enormously. She
looked, in fact, as a woman, thin as she was, would
have looked at the eighth month of pregnancy.
Other attacks were less severe, but always they
lasted for some hours before she could stand up, and
it was usually a week before she was well.

When I saw her an attack was at its worst. The
woman's pulse was about 165, and was a mere thread

17^-

198 DISEASES OF THE NERVOUS SYSTEM.

at times imperceptible. Her face and limbs were
white and cold. The abdomen was tense and red,
and could be felt to throb distinctly, while all over
it the vessels, veins, and arteries were visibly en-
larged. On listening over the belly I could hear a
humming noise, a slight thrill. The chest itself was
not quite so pale as the neck or face, but the breath
was difficult and rapid. It was clear that owing to
palsy of all the abdominal vessels, all the available
blood of the body of a too bloodless w^oman was for
a time in this cavity and its walls. If while in this
state she sat up she instantly fainted, and it was
difficult even to lift her head, because of the symp-
toms thus caused. She herself complained of the
tension of the belly, and of the distressing pulsation
within it.

The day after, the abdomen was certainly a third
less, and it was then seen by Dr. Keating, who, like
myself, could give no other explanation of the con-
dition seen, than the one I have just mentioned.
After a week the belly became nearly as flat as usual,
and I then ceased to see my patient. I learned from
her some years later that by slow degrees she had
become well of this singular malady.

Yet a few words before I abandon this subject as
to the irregularities of breathing in the hysterical.
These may accompany cardiac disturbances, which
is rare, or may exist alone, without elevation or
altered rhythm of pulse. In other forms of disease,
as you well know, when the breathing becomes
rapid, the pulse also proportionally increases in
number; and it is uncommon to see excitement of
heart from fever or inflammation without a like rise

VASO-MOTOR DISORDERS. 199

in the rate of respiration ; but hysteria breaks all
laws, except its own rules of eccentricity.

I have seen a woman with a respiratory rate of
10, and a pulse of 100 ; another, with a pulse of 30,
and a normal speed of breathing.

There is now in this hospital a case of hemi-anses-
thesia and hemiplegia, getting well after two years
in bed. When she began to walk about, two months
ago, her pulse was 60 to 70; her respiration 15 to
18. My assistant soon after observed that the rate
of breathing was increasing, and, without calling
attention to it, we began to keep daily notes of it,
and of the heart and temperature.

The average pulse, early in N'ovember, was 75-85
in the morning and evening respectively. Eespira-
tion 16-17.

At the close of December the pulse had slowly
risen to an average, for the two daily observations,
of 94.1, with, nearly always, a rather faster pulse in
the mornings ; but, meanwhile, the breathing rose
to a daily average of 49.4.

Some of the numbers are remarkable. I give in
a brief column one week, for comparison with
healthy states :

Pulse.

Respiration

Morning.

Morning.

10 A.M.

10 A.M.

Dec. 22.

102

50

" 23.

100

52

" 24.

98

57

" 25.

90

55

" 26.

95

37

" 27.

98

55

" 28.

93

49

Mean

99.3

50.7

Pulse.

Eespiration

Evening.

Evening.

10 P.M.

10 P.M.

91

48

99

53

100

62

87

47

85

39

. 88

44

88

89

91.1 47.2

200 DISEASES OF THE KERVOUS SYSTEM.

The respiration was singularly tranquil, despite
its rapidity, and there was not the slightest appear-
ance of effort. Digitalis, given in half-ounces of the
infusion, seemed to have no effect on the pulse after
some days, but so disturbed the stomach that I was
forced to give it up. The thirtieth of a grain of sul-
phate of morphia brought down the breathing one-
fourth, and the one-twentieth of a grain had a still
more perceptible effect, so that the average respira-
tions fell for the last week to 28.1, while the average
pulse was 81.2. A single full dose of opium, given
to relieve pain, brought the respiratory rate from 58
to 17 within a few hours ; the pulse falling at the
same time from 88 to 73.

This is a remarkable example of a rather unusual,
but sometimes overlooked, hysterical symptom. In
a doubtful case it alone would decide the diagnosis;
for a like condition, outside of hysteria, is a clinical
curiosity.

'Nov is this a mere theoretical idea. A few years
ago I was one of three physicians called to see a lady,
long ill with a variety of ailments. She had passed
into a state of stupor, from which, for two days, it
had been' impossible to arouse her. I observed that
while her pulse was about 90, her breathing was
almost imperceptible; on careful count, however, it
proved to be 96 in the minute, from which I was
sure that the case would prove, in the end, to be
hysterical ; an opinion justified within a few hours
by the repeated occurrence of very violent hystero-
epilepsy.

Dr. John H. Brinton and I have reported a very

VASO-MOTOK DISORDERS. 201

remarkable case of rapid respiration in a man. It
is so rare an illustration that I think it worth while
to rescue it from the records of the College of Phy-
sicians and place it here in relation with hysterical
states of rapid breathing not due, like it, to a
definite lesion.

J. W. B., E. Co., 57th Pennsylvania Infantry
Volunteers, set. 31, shot at Fair Oaks, May 31, 1862,
by a ball from a sharp-shooter in a tree, at about 80
to 100 yards distance. The colonel (Campbell), who
was shot at the same time, and from same source,
was hit by a conoidal ball, which was removed from
his arm. It is probable that Barnes was also hit by
a conoidal ball. The wound of entrance, the patient
says, was like a clean cut, near the centre of the base
of the scapula, the direction of the ball was down-
wards and forwards, and the ball lodged apparently
behind the cartilage of the 7th or 8th ribs, about two
inches from the sternum on the right side.

The patient states that at the time of injury, he
felt as if he had been ^'hit hard on the back by a
stick; he also felt as if he was hurt or torn ante-
riorly behind the cartilages of ribs of the right side.
At the moment of injury, there was no shock, but in-
stantly bloody expectoration, not copious, only two
or three mouthfuls, dark-red, not bright-red. The
dyspnoea was great, but he did not faint. In a minute
or two after being hit, he suffered from nausea, and
some shock, but there was no vomiting. He did
not fall. He was not able to lie down, on account
of dyspnoea, but was able to sit. He rode, sitting on
the front seat of an ambulance, to Savage's Station,

202 DISEASES OF THE NERVOUS SYSTEM.

was there placed on a chair, taken to James River,
and then on a steamboat to Philadelphia, where he
was carried from the depot to St. Joseph's Hospital
(fully two or two and a half miles) on a furniture
car; but during all the time from the day of injury
to June 16th he did not lie down or leave his chair —
the same one on which he was placed at Savage's
Station. Immediately after being hit (within an
hour), great emphysema from the jaw down to the
pelvis on right side occurred, for which he was
bandaged at Savage's Station,

June 4, 1862, admitted to St. Joseph's Hospital,
from which he was discharged on the 16th of June,
the wound having healed. He reentered the hos-
pital on the 24th of July, and was then treated for
inflammation of the right pleura, and was discharged
from the hospital early in December, 1862. Since
that time, there has been constant pain in the right
chesty aggravated by exposure. He married in 1862,
after leaving the hospital in Philadelphia.

Since December, 1862, he has tried railroading,
but found the exposure too great. Shopkeeping was
too confining; could not continue as a street-car con-
ductor, from inability to speak at times, consequent
upon spasmodic action of diaphragm. Is now (March ,
1870) the proprietor of a book-stall or newspaper
stand in the open air. He weighs about 121 pounds,
having fallen to this from 150 pounds, his former
weight.

He has haemoptysis about twice a year, amounting
to a few small mouthfuls of blood during the day.

VASO-MOTOK DISORDERS. 203

for two or three days. He has now such an attack.
Has not had one for six months previously.

Examination of Chest. — Measurements : Right chest,
at level of inferior angle of scapula to middle line,
one inch below right nipple, 11 inches. Corre-
sponding measurement left side, lOJ inches.

There is pain on pressure, on right side of spine,
from the 3d to the 6th vertebra, between vertebral
spine and posterior scapular margin. The wound,
which is perfectly cicatrized, is on a level with the
5th vertebra, and about ^ of an inch from the posterior
margin of the scapula. Great tenderness over all the
muscles, between the posterior margin of scapula
and vertebrae, and up to a point 2J inches above
cicatrix, and J below the middle of spine of scapula.
Hypergesthesia of surface in an area extending from
1 inch below to 2 inches above scar.

A very tender spot was detected, 5 inches below
the posterior angle of the axilla, between the 7th and
8th ribs. Tenderness was also evident 2 inches in
front of that point, and extending from the 5th to
the 8th ribs.

On the front of the chest, tenderness on pressure
existed one inch above the right nipple, extending
to the middle sternal line, and downwards as far
as the margins of the costal cartilages. The extreme
of tenderness was marked by a line drawn obliquely
downwards from the right nipple to about the ante-
rior margin of the 8th costal cartilage. General
hypergesthesia of surface existed over this tender
region.

The patient experiences pain when he bends his

204 DISEASES OF THE NERVOUS SYSTEM.

body forwards ; and when he wishes to seize an ob-
ject on the floor, he crouches, bending both knees
alike. He himself believes that the ball lies at the
front and lower part of the right chest, and that it
shifts when he attempts to laugh or sneeze, or bend
forwards.

That some unknown lesion probably exists at the
point indicated, we may readily conceive, and we are
inclined to think that a sac of false membrane exists
immediately behind the costal cartilage, and in the
vicinitj^ of the diaphragm ; and that most probably
this sac contains the ball ; we think moreover that
the sac is of some size, and that the ball is loose.

Anteriorly the inspiratory and expiratory sounds
were heard throughout both lungs, but they were
very short and somewhat rough, owing, perhaps,
to their speed. There was no loss of respiratory
space at the site of the pain below the right
nipple, nor was there any unusual dulness there-
abouts.

Transmitted heart sounds were heard about two
inches below the right nipple, masking, and to a
certain extent confusing, the respiratory sounds.

Percussion over the right lung anteriorlj^, even
when practised with the utmost gentleness, produced
great pain and dyspnoea; especially was this the case
when percussion was made over the swelling at the
costal margins, the supposed locality of the ball.

The upper part of the right lung was clear on per-
cussion, shading down to the ordinary level of liver
dulness, and becoming more dull over the costal
swelling.

VASO-MOTOR DISORDERS. 205

Posteriorly, respiratory sounds were heard over
both right and left lungs, more distinctly, perhaps,
over the left lung.

Dyspnoea has been present in the case from the
time of injury. If he laughs heartily, violent dys-
pnoea amounting almost to suffocation is induced,
followed by great prostration.

The marked feature in Barnes's case is the rapid
respiration. Usually when at rest it is a little slower
than the heart-beat, sometimes it is almost synchro-
nous with the latter. On exertion the respiration
rises rapidly, so as to exceed the heart-pulse in num-
ber. Thus :

Feb. 27. — Patient sitting quietly in his own room.
Pulse 74; respiration QQ.

March 3. — One hour after supper, having walked
about a mile, he was examined in a standing posture.
Pulse 90 ; respiration 76 to 78. Examined in
recumbent posture. Pulse 78 to 80; respiration 64.
On the same evening the patient was directed to run
twice up and down one short flight of stairs. Then
pulse 100; respiration 108 or 110.

13/A. — The respiration and cardiac movements
were synchronous, viz., 78. A little exercise sent
the pulse to 95 and the respiration to 125.

14^/i.— After a short walk, pulse 100 ; respiration
120. From the date of the wound until March,
1863, his breathing was almost thirty times to the
minute. At that time over-exertion is said to have
caused the present rapid rate.

Prior to his being wounded this patient was an
accomplished diver, and could hold his breath for

18

206 DISEASES OF THE NERVOUS SYSTEM.

over a minute ; now he can hold it only for a few
seconds. When he does so the heart-pulse becomes
somewhat slower, a proof of the integrity of the
pneumogastric nerve.

The heart does not seem to be injured seriously
by the long-continued speed of the respiratory
movements, at least its valves have not suffered,
although the first sound is often faint, as if there
were a feeble left ventricle. This would seem likely
to be the case from the appended sphygmograms,

Fig. 1.

Tracing of sphygmogram of Barnes's pulse when lie is quiet.

Fig. 2.

Tracing of sphygmogram of Barnes's pulse when exhausted by exercise.

taken by Dr. Mitchell, and which indicate a feeble
heart and a relaxed arterial tension.

A marked feature in B.'s case is the peculiar
facial spasm which occurs some fifty or sixty times
a day. During each one of these spasms the lower
jaw is pulled down once or twice, and respiration
and speech are arrested. Each spasm begins with
pain over the hyperaesthetic space in front.

The loss of poAver in the upper extremity of the
right side is very evident. The patient states that
immediately after being shot he dropped his gun,
and that for six months he could not elevate his
right arm. He states "that the shoulder was
paralyzed."

VASO-MOTOR DISORDERS. 207

At present he cannot raise the arm above the
level of the shoulder, and the grasp of the right
hand is very feeble, contrasting strongly with that
of the left hand, which is remarkably vigorous for
one of his build.

The want of power in the right hand points to the
probability of its having been due to a reflex paral-
ysis originating in shock at the time he was wounded.
Indeed there seems to have been sudden loss of
power at the moment, and certainly no amount: of
disuse possible to a man who has to do even light
work will account for the vast disproportion between
the strength of the two forearms.

This singular case gave rise to much debate when
it was shown by us to the Fellows of the College,
but no satisfactory explanation of its phenomena
w^as ever obtained.

208 DISEASES OF THE NERVOUS SYSTEM

LECTURE XII.

HYSTERICAL APHONIA.

The patient before us to-day is a very notable illus-
tration of the pranks which may be played by
hysteria. I read you her history, and as you hear it
I think you will see that almost at any time a reso-
lute man, whom she trusted and who understood
her disorder, could have saved her and her family
from long years of suffering. Her case will enable
me to point out to you, as I have done very often
before, that the natural history of many of the forms
of hysteria is still an open study. One reason for
that is, I presume, the disgust with which the gen-
eral practitioner encounters this malady. It is
hysteria, and with that seems to end all need for ob-
servation of details and varieties of symptoms, such
as more manageable disorders obtain.

Mrs. R!, aet. 31, from ISTew Jersey, was brought up
among people of narrow means and larger wants.
A rather frail constitution and nervous parents
doubly prepared her for the ills which were, perhaps,
only hastened by an attack of ague, followed by
pneumonia, in September, 1870. Soon after recovery
a day of fatigue and some worries ended in hysterics,
with retention of urine. A more violent fit followed
an attempt to do some rather hard work. From this

HYSTERICAL APHONIA. 209

time the Pandora's box of hysteric ills was opened,
and they came almost without limit. Remaining in
bed, fit followed lit, until, when a little better, she
chanced to smell musk, upon which she fell into a
state of stupor, and was thought to be dying. Then
the voice fell to a whisper, and so came and went for
five years, and at last failed so utterly that for the
last five years she has uttered no sound. Meanwhile
she stayed in bed till 1872, and had, in succession,
general paresis, right arm and hand paralyzed,
enormous swelling of hand so as to resemble an ab-
scess, and a variety of hypersesthesias ; on one occa-
sion a blow on the hand caused retraction of the
head, followed abruptly by recovery of previously
lost power. Soon afterwards there were in succes-
sion repeated attacks of hemiplegia, renewed hys-
terics, paralysis of left leg, and swelling of foot, with
exquisite hypersesthesia of the whole skin. In Sep-
tember, 1872, a slight effort brought on palsy of the
left arm, so that she had finally loss of power in both
hands, with loss of voice. This was followed by
anuria, and then by complete absence of saliva, so
that for a time the mouth was absolutely dry. Mean-
while speechless, and with paralysis of all her limbs,
she could only call any one by seizing the handle of
a small bell in her teeth and shaking her head.
After a year and a half the use of induction-currents
seemed to have a good effect, and she was soon able
to use her hands, and to walk. At this time and for
seven years the right hand swelled enormously before
each menstrual flow, and at the close of the week
the skin came off in large patches. In 1876, she

18*

210 DISEASES OF THE NERVOUS SYSTEM.

had violent retro-spasms of the head and motor
ataxia of the legs. In 1877, she had hysterical con-
vulsions, photophobia, a variety of pains, glossitis,
with great swelling of the tongue, long attacks of
coma, hysterical vomiting, and two weeks of nearly
complete fasting, and spasmodic ptosis.

You will, I think, agree with me that a more
miserable catalogue of ills could hardly be made out.
Within a year the active troubles have faded away,
and we have before us only a weak, pale, sensitive
woman, with complete loss of voice.

You will remember that this woman was at my
last clinic, and that I told her she could probably
learn to speak. Two days later she wTote me that,
for the first time in ten years, she had made a sound,
and this is all, but in the mean while I asked her to
come to my house, and there I studied her case yet
more carefully ; and now to-day she comes back, and
I shall test the value of the theory I have formed as
to her case. But, before I do this, let me say a few
words as to the types of aphonia and dysphonia con-
nected with hysteria. You will find in Cohen's
excellent book, and in Ziemssen, very good accounts
of this group of disorders, but 1 think it will admit
of further study, and I, therefore, venture here to
tell you about it some things which are not found in
the text-books.

Hysterical loss of voice is apt to come on in long
cases of hysteria without apparent cause. The voice
goes and comes, is hoarse or feeble, and at last be-
comes reduced to a whisper, or is lost altogether for
w^eeks or years. Then the patient has to write what

HYSTERICAL APHONIA. 211

she would have talked ; and if, as in this girl's case,
her arms be palsied for a time, only manual signs
remain until the people around her learn to read
those labial signs with which communication at
length becomes so easy as to take away desire to
make the painful effort at audible speech.

In a few cases emotion causes abrupt loss of speech
power. Cohen relates such a case; I have seen
several. I^or when we remember that it is through
the voice-muscles that we express so many of our
emotions, can we wonder that it is in the larynx that
we feel the choking spasm of grief, or that here, also,
intense sense of pathos, or almost any deep feeling,
asserts its power by some act of muscular spasm ; or
that in nervous people yet graver emotional shocks
result in palsy of the organs through which we are
prone to express emotion.

There are, as I have seen them clinically, at least
three forms of hysteric conditions which disturb
vocal utterance, and these three forms are sometimes
all seen in one case, or may exist distinct. We have,
first, bilateral palsy of the adductors of the vocal
cords; second, disassociation of the functional activi-
ties of the various organs needed in phonation; third,
habitual spasm, or sense of spasm, during use of the
larynx in speech.

The first, or bilateral loss or lack of power in the
crico-arytenoid muscles, is the common type of hys-
terical aphonia, and is usually found with loss of
power in some of the other muscles of the larynx.
If, in a case of hysteria, you have loss of voice, or
suddenly the patient becomes a whisperer, you may
be pretty sure that you have to deal with this form

212 DISEASES OF THE NERVOUS SYSTEM.

of trouble. Even if there has been a cold and sore
throat, with cough, you may safely conclude that the
slight local inflammation did not cause the aphonia,
but acted as what I may call a hint to the hysterical
condition. This caution is, I may add. the more
needed because an outbreak of this form of trouble
is often caused by catarrh ; but this is the kind of
thing we see every day in hysteria. The catarrh
passes into hysteric paresis. A diarrhoea from over-
eating becomes a hysterical diarrhoea; an attack of
true emesis from indigestion is the parent of hys-
terical regurgitation, and this may last for years.

Bilateral hysteric palsy of the vocal cords may be
extreme or slight, but where it is marked you will
see, with the laryngoscope, that the cords do not
come well together when the patient makes vowel
sounds. One cord may come nearer the middle line
than the other, but neither does its duty. This is an
easy examination commonly, because, as a rule, hys-
terical people are not at all disturbed or gagged by
the mirror ; but this is not alv/ays so, and the patient
we see to-day has a quite sensitive throat. If you
find a distinct unilateral glottic palsy, you have,
probably, a non-hysterical paralysis — at least I have
never seen a monoplegic state of larynx which was
hysterical. You would naturally suppose that
aphonia and dysphagia would often be found to-
gether, but this is rare, very rare, although I can
recall cases where the two disorders alternated.

The loss of voice in hysteric aphonia has some odd
peculiarities, or rather exceptions: the patient cannot
speak, or can only whisper with mouth or larynx so

HYSTERICAL APHONIA. 213

faintly as to be scarcely heard with the aid of the
ear-trumpet; yet she may be able to sing well, as
happened in one of Cohen's cases ; or, as chanced in
that of a lady whom we saw together, she may be
able to speak aloud in her sleep, and then only. On
these occasions the unwonted sound of her own voice
would awaken her, and the disappointment which
followed the next waking effort at speech was most
distressing, and the emotion thus occasioned gave
rise, like all emotion in such cases, to an even greater
loss of what mere whispering power was left.

Many examples of these disorders are seen in
pretty strong, stout, and even ruddy women, and
when met with in such persons are, like all the hys-
terical phenomena of the nearly healthy, especially
unmanageable. When hysteric aphonia is found in
feeble and easily tired women, the effort to speak or
cough with an open larynx, or with weak chest
muscles, gives rise to a good deal of soreness, and
emphasizes that sense of painful fatigue about the
pectoral region of which this class of invalids is so
apt to complain. The victim of this disease is very
often able to speak low, the voice breaking at times.
Other and extreme cases lose the power to whisper
with the larynx, but can still whisper with the
mouth ; and others, again, are unable to utter the
faintest sound, or to laugh or cough so as to be heard
at all. It must be obvious to you that, in the worst
cases, we have here a dual condition, a paralysis
which, though without coarse organic cause, may be
lasting, and a disassociation of the motor activities
of the respiratory, laryngeal, buccal and oral mus-

214 DISEASES OF THE NERVOUS SYSTEM.

cles — parts which, bj physiological construction
and long habit, unite to produce voice. The two
troubles are often seen together in variable degrees;
or the incoordination may exist alone, there being
still power to close the larynx.

We should then have the second and less well-
known form of aphonia, and this it is well to study
with care. The present case is a perfect example.
If while using the throat mirror, I ask her to sound
the broad A, the vocal cords come together, but do
not vibrate, because she is unable to use synchro-
nously the respiratory muscles to drive air through
the narrowed orifice. Of course, there is no laryngeal
whisper. In some of these cases, as I have seen, the
patient can whistle more or less well, because for
this act only the mouth and an expiratory effort are
needed; but there are others who cannot execute
even this simple act of coordination, and these per-
sons would seem, therefore, to have also lost power
to use vocally the lesser bellows — the mouth — in
connection with the tongue and lips, so that in this
case buccal whispering would also be lost, and the
patient would then have what Cohen calls apsithuria,
and be absolutely whisperless. I will defer speaking
of the third form of dysphonia until we consider the
case before us. This young woman has good power
over the laryngeal muscles. I ask her to speak ; she
makes a great effort, but, as I found in my^last
examination, I cannot hear her even with an ear-
trumpet. She has neither with larynx nor mouth
capacity to whisper. She can whistle feebly, but
whistling is not a feminine accomplishment, or she

HYSTERICAL APHONIA. 215

might do better. You observe that, when trying to
speak, she makes extreme movements of the lips,
and this is done to enable her friends to read this
language of oral signs which she thus renders clear
or emphatic.

What I have here said describes well enough this
curious condition, which seems not to have been very
clearly recognized as being sometimes a state apart
from paralytic conditions. I can give no explana-
tion of the immediate causes of these singular inco-
ordinations. Let us now test their presence. It has
occurred to me that, if I could teach her how once
more to use with success these disunited activities,
she might regain her voice. On thinking how I
could best bring this about, it seemed to me that, if
I could teach her to speak only with a very full
chest, I might secure an involuntary success in driv-
ing air through the larynx. I shall ask her to fill
her lungs several times, and, when very full, to keep
her mouth wide open, and, as she sounds or tries to
sound the broad A, to breathe out violently. I aid
her by myself performing the act. To her surprise,
for the first time in ten years, she makes a clear,
audible sound. Then, always insisting on each single
letter being made with very full chest, we go over
the vowels, and then try the labials, and at last words.
As she leaves me she says, " Thank you." I insist
that she shall not speak save with a full chest; that
she must never use oral signs alone ; and that she
must be silent except during the lessons her sister
will now give her thrice a day.

If this had been a case of glottic pals}', I should

216 DISEASES OF THE NERVOUS SYSTEM.

think her sudden cure was due to the emotions
caused by her novel treatment, as Cohen has seen,
and I also, the mere use of the throat mirror restore
voice ; but at her first visit here we got no result
from this or from Oliver's method of manipulating
the larynx, so that I myself shall believe that the
result was due to my teaching unused organs the
easiest way to regain their habitual function.

Under the use of tonics, rest, and full feeding,
with vocal lessons, and a continued order not to
speak at other times, she has continuously improved.
Whether or not she will relapse depends a good deal
on her surroundings. Such cases are only too prone
to fall back.

Hysterical spasm of the larynx is a phrase which
I almost hesitate to use, since I cannot be absolutely
sure that the disorder I shall describe is really due
to this cause. There are few of us who, at some
time of our lives, have not known the sensation of
choking in the throat from emotion. It is a brief
and unpleasant matter, and for well people a rare
one, but among highly nervous people, or hysterical
women, there is a rare form of this trouble, or some-
thing allied to it, which gives rise to temporary loss
or inhibition of voice. At first from emotion, wor-
ries, or without known cause, there is felt in or about
the larynx a sense of momentary strangling and pain.
If the person is speaking, the voice breaks, and she
remains speechless, or the voice becomes shrill and
then breaks. At every effort there is pain, distress
referred to the larynx, and squeaky, broken tones.
There is also a sense of constriction, and sometimes

HYSTERICAL APHONIA. 217

the oesophagus seems to share in the annoyance, and
an upward gulping effort follows or accompanies the
laryngeal disturbance. I have seen this group of
symptoms become so frequent in one case, that at
length the girl refused to speak at all. It was apt in
this case to follow meals, and these were seasons
of real suffering, because of the intense dysphagia,
which caused her to chew every morsel for many
minutes before venturing upon the task of degluti-
tion. The meal became, therefore, a severe strain
upon an already feeble constitution, and this seemed
to have something to do with the more ready causa-
tion of the laryngeal disorder at these special seasons.
A long course of milk and soup diet, inhalations
of nitrite of amyl, and galvanization of the larynx
finally relieved greatly these troubles, but there was
no entire cure until a year later I succeeded in
materially improving her general condition.

We have, then, laryngeal palsies usually with,
sometimes without, incoordination of the chest, dia-
phragm, and mouth ; pure incoordination without
paralysis ; and, lastly, a disease which seems to be a
temporary spasm of the vocal muscles of the larynx,
caused by effort at speech — in other words, a func-
tional spasm.

19

218 DISEASES OF THE NERVOUS SYSTEM.

LECTURE XIII.

HYSTEKICAL JOINTS.

I DO not mean to go fully into the history of dis-
ordered joints. More than one of the great masters
in medicine have described them, and I shall not en-
deavor to better what has been done by Brodie and
Paget. I judge, however, that the subject has still
its grave difiiculties, because I can recall numerous
erroneous surgical decisions in regard to these per-
plexing cases. There is now in the Infirmary for
J^ervous Diseases, a topical example of the malady
in question. It has been a stumbling block to more
than one physician, but came hither correctly
labelled by Dr. Halberstadt, of Pottsville. I will
state the case briefly, as I desire to show by contrast
with another how difilcult it may be to reach an un-
troubled conviction as to the diagnosis of certain
rare examples of joint disorder.

Here is in brief this girl's story. A fall on the
knee is followed by pain and a long rest — other falls
occur with like consequences — finally one results in
acute hysteria of which Dr. Halberstadt speaks as
follows :

''When first I saw Miss B., she complained of in-
termitting pain in the head, left eye and foot, the
ears and the left thumb, her eyes were sensitive to
light, her arms and legs were rigid in extension.

HYSTERICAL JOINTS. 219

Heavy sweats kept her bed-clothes wet. Her respi-
ration was 180, and her pulse so rapid that I could
not count it. These symptoms I watched for over
two hours, her mother declaring they had existed
steadily for five weeks. The whole body moved in
curious jerks at each inspiration, and her appearance
was that of being worked by punctual machinery.
I could detect no disease of the kidneys nor of the
uterus."

When we saw this girl here a year later, the left
knee, thigh, and leg were solidly bandaged with
caoutchouc and flannel. The knee seemed large
from contrast wdth the leg above and below, where
disuse, for she always used crutches, and incessant
bandaging had caused such atrophy as disuse and
pressure will bring about. The muscles reacted
perfectly on both sides, the knee jerk was equal, and
there was only slight flexion of the knee, and this
disappeared in sleep and was easily reduced. All
the graver hysterical signs elsewhere were gone.
The health was good and all functions in order,
there was not even the least loss of sensation.

This w^as purely a hysterical joint and nothing
more. Massage and induction-currents were used to
awaken the unused muscles, bandage and crutch
were put aside, and after a few words of kindly ad-
vice she was ordered to walk. In a week she could
walk five miles, and went home to have, I trust, no
relapse.

No case could seem more simple to one accus-
tomed to see hysteria, but you will be gravely de-
ceived if you think that it is always made as easy to
decide as to tlie origin of lesions of joints.

220 DISEASES OF THE NERVOUS SYSTEM.

If there has been but one factor, decision ought
to be readily reached ; but if there has been a real
injury or true joint disease, and with it hysteria oi;
this latter condition primarily, and inflammatory
joint lesions supervening — you may have problems
of exasperating perplexity. In the case last men-
tioned, we had a hysterical history — normal electrical
reactions, pain without heat or swelling. Let us
contrast this with that of a patient who was for
years a too interesting example of joint disease, and
has puzzled Dr. Shaffer, of E'ew York, and myself
and others at home and in Europe, for a very long
time. Her case is one which I may well afford to
state at length.

I shall pass briefly over the early histor}^ A girl,
set. 16, of good tint and fair amount of flesh, came
to me suffering with hemiplegia of the right side,
unusual loss of power, analgesia, defective sense of
touch and of temperature, hysterical emesis, habits
of eating paper, dysuria, rectal pain, etc. After much
treatment she became well enough to walk, but for
some time longer exhibited a perfect type of hys-
terical ataxia. The sensory losses lessened by de-
grees, chiefly in that they were not so general over the
whole side; but a few months after she passed out of
my care the left leg contracted slightly at the knee,
and the joint began to be subject to great pain. This
group of symptoms developed further until the foot
became extended, the leg bent at a right angle on
the thigh, and the latter flexed on the pelvis and
strongly adducted. The knee also became more
swollen, and all motion was described as agonizing.

HYSTERICAL JOINTS. 221

The history of this knee was interesting and worth
considering, in the light of some of the tests usually
accepted as of diagnostic value.

In January, 1882, the leg muscles were as above de-
scribed. The left knee measured one inch more than
the right knee. Its contours were decidedly altered
and it was encased in a brawn-like tissue, especially
at the back and sides. The patellar reflex was
nearly alike on the two sides; there was no ankle
clonus. The muscles of the left leg were all some-
what wasted, the calf being an inch less than that of
the right side. The electrical tests showed only
quantitative lowering for all currents, and not very
decisively. The foot was still extended, the heel
drawn up, and the leg bent on the thigh.

All day long the joint, unless touched, pressed, or
handled, remained at about the temperature of its
fellow, or a half degree below it, but always between
9 and 9.30 in the evening an interesting change took
place. The knee became more swollen and the skin
all over it grew very tense, shining, and of a deep
red. To touch or shake the part occasioned great pain.
The temperatures were carefully studied by placing
a surface thermometer, guarded by a grooved cork,
on the inside of each knee. The right gave always
very similar readings from day to day, only once
rising at night to 98° F., and commonly not varying
much above or below 96.8° to 97.1° F.

The Table J^o. Y. shows the curious ranges as re-
gards the left knee, which rose in temperature at
night from 1 to 4° F. The pulse remained always
about 80; but between twelve and three all the local

19*

222 DISEASES OF THE NERVOUS SYSTEM.

conditions of heat, redness, swelling, tension, and
increased pain passed away. The same set of symp-
toms could be brought about at any time by han-
dling the knee. Even pressure on the patella was
followed by an exhibition of like phenomena over a
smaller area.

In February, 1884, I saw this lady in consultation
with Dr. Shaffer, of ISTew York, in that city. We
found much the same state of things as when the
joint had been last seen by me. Atrophy from dis-
use, lessened faradic electrical reactions, reflexes
entire, and the muscles contracted always, but more
relaxed when her attention was taken away from
them. The usual will-lessness, if such a word be
allowable, was observable in many of her acts, and
the knees were much as before.

Dr. Shaflfer and I were of opinion that, notwith-
standing the pain and the remarkable changes in
the form and size of the knee, there was no evidence
of any lesions of the joint itself, and that the changes
mentioned were external to the articulation. It was
certainly unlike a synovitis, and still more unlike
articular osteitis, nor did it resemble at all any-
thing known to the books. I describe, in the next
lecture, a not altogether dissimilar affection, in
which it was difficult to say how much was hys-
terical and how much due to limited organic dis-
ease of the spinal cord.

In the present case, some wasting and much con-
traction preceded the complaints about the knee,
so that the order in which the symptoms followed
one another points to the contractions as hysterical,

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224 DISEASES OF THE NERVOUS SYSTEM.

and not as due to articular disease, while this might
also have been inferred from the form of these con-
tractions, the muscles aiFected, and the intensity of
the symptom. Our only doubt would be as to the
knee. Was that hysterical only, or was there in it
some coarse organic lesion ? My own decision has
always led me to class it as purely hysterical, and,
recalling the local temperatures, the absence of gen-
eral fever, the peculiar vaso-motor changes, the pres-
ervation of the knee reflexes, and the fact that the
electrical reactions were better than the amount of
wasting would have led us to expect, recalling all
these, I say it is hard to decide otherwise than for
hysteria.

We have had here to deal with a hysterical wo-
man, a hysterical leg, a hysterical knee-joint, and
the supervention of changes about it, and, possibly,
in it, which must be looked upon as new and pecu-
liar in the pathological history of joints.

While these pages were in press, I received from
Prof. Henry Sands, of I^ew York, some facts as
to the later history of the case.

Miss — — went to Europe in June, by advice of
Dr. Shaffer and myself. In Germany she consulted
Dr. Bettleheim, who, in his letter of advice, describes
the knee as swollen with synovial fluid, and states
that probably the cartilages and ends of the bone
were thickened. His impression was that there was
a spinal myelitis on a hysterical foundation. Pro-
fessors Billroth and Nothnagel considered the case,
as I do, as a most unusual one, and advised that
measures be taken to cause ankylosis, believing that

HYSTEEICAL JOINTS. 225

the patient would thus be made more comfortable,
and that, of course, the contractions would disap-
pear. Prof. Billroth seems also to have believed
that some fungous products would be found in the
joint. " In accordance with these views," says Dr.
Sands, " and with much doubt as to the character
of the disease, and a full sense of the obscurity of
the case, I laid open the joint freely, using fall anti-
septic precautions, and explored it thoroughly. I
found the joint surfaces normal, the enlargement
being due to plastic infiltration of the fatty and con-
nective tissues, outside the capsule. The thickening
was due to ordinary inflammatory products, and was
evidently not tuberculous. The wound was closed
and the leg put on a straight splint, in the hope
that ankylosis would result. No inflammation took
place in the joint, and, as soon as the limb was re-
leased, the contractions gradually returned. Then
the leg was placed in a plaster splint, but the patient
complains incessantly and bitterly of pain in the
joint, while declaring also that her suflerings have
been lessened by the operation."

For those who believe that hysteria never gives
rise to organic changes this case will certainly be
fall of instruction.

Of course, cases like this — cases as difficult to un-
ravel— are rare ; but it is a mistake also to suppose
or assert that the neuro-mimetic joints, where dis-
ease is simulated, are always free from swelling, and
even from redness and heat; but, then, the nature ot
the swelling, the character of the redness, the time of
the temperature changes, the relative mobility under

226 DISEASES OP^ THE NEKVOUS SYSTEM.

ether, and the state of the muscles should in all cases
make mistakes impossible, except for ph^^sicians who
fail to see sign-posts as plain as these.

This is not the only case in which I have met
with high temperatures of a joint at night; usually
Sir J. Paget's dictum is a safe guide, when he tells
us that "a joint which is cold by day and hot by
night is not an inflamed joint — that is certain."^

It remains to be said that many hysterical joints
are associated also wdth contractions of hysterical
origin, and which cause enough and sufficiently
prolonged immobility to give birth to that really
painful state of a joint so readily caused by too long
use of a splint.

It is also worthy of remark that the knee is the
joint most subject to hysterical disorder, and that the
smaller articulations are not often complained of.

^ Clinical Lectures and Essays. See also for the best essay on
the comparative symptomatology of hysterical and inflamed joints,
N. M. Shaffer, op. cit.

ORGANIC DISEASE OF THE SPINE. 227

LECTURE XIV.

HYSTEEIA AND ORGANIC DISEASE OF THE SPINE.

I HAVE recently been endeavoring to learn from
mj recollections and my note books what share of
old hysterical cases pass into a condition of organic
disease of the spine. I can thus recall eleven cases
of which I have, or have had, knowledge as bed-
ridden hysteric patients for at least twenty years.

Five of these presented more or less rigidity and
contraction of the leg, and in one the contractions
were extreme. In all of the rigid cases and in two
others there was sensory impairment. I have notes,
more or less complete, as to the electrical conditions
in all of the instances of contraction. In three there
was or is only impairment of response to faradic
electrical excitation. In two there exist all the
ordinary defects represented by R. D., or reaction of
degeneration. These two are probably, I may say,
surely examples of hysteria which has terminated in
an alliance with organic disease of the anterior regions
of the spinal cord. Such cases must, I think, be very
rare and without an extremely careful examination
with all the electrical tests, mistakes may readily be
made, and a verdict of permanent and certain dis-
ability pronounced over what is still only and purely
a case of hysterical contraction, and anaesthesia with

228 DISEASES OF THE NERVOUS SYSTEM.

the atrophy which comes of disuse and artificial im-
mobilization. I may go a step further, and say that
even in some hysterical cases where the full elec-
trical signs of degenerative change exist supported
by ample ocular evidence in other directions, we
may sometimes accomplish more in the way of relief
than we could expect to do in most cases of spinal
change apparently as distinct, and where no hysteria
was involved. I have seen several such cases, and
one of them I shall presently relate. Because of
their so complete recovery I have felt a certain hesi-
tation as to retaining my opinion that grave changes
in the cord had been a part of their pathology. I
feel quite sure that no neurologist would have seen
the case I shall state in justification of my doubts,
without to some extent sharing them.

Apart from the diagnostic difliculties there are
other reasons why I state this case at some length,
and why I regret that its early history has never
reached me in as full a shape as I might desire.

Mary B., set. 19, late a student at a girl's college;
height 5 feet 6 inches ; weight at her 17th year, 156
pounds; florid complexion, light colored hair; of
natural intelligence, ambitious, and studious, but not
remarked as emotional or morbid. The family his-
tory is exceptionally good.

Miss B. had scarlatina at fourteen, followed by
jaundice and emesis at intervals for a week. In
1877 she had a like attack of vomiting, without
pain or jaundice.

In June, 1880, she was graduated at a high school.

ORGANIC DISEASE OF THE SPINE. 229

and in September went to a college for women, where
she worked very hard. In March, 1881, she returned
home, very tired, for a brief vacation. Here she had
a headache of great severity for a day, and was left
by it rather weak, and disturbed by occasional ver-
tigo. Resuming her studies with difficulty, at the
fourth day she once more broke down, and became
abruptly peevish, irritable, very feeble, and sensitive
to noises and light. At times her vision became
blurred, a part of the whole field being lost for a
time. Meanwhile, for a week, she kept her bed,
without fever and with fair appetite.

April 16th, she again went home, sleeping ill,
and much as above described.

I am told that upon April 30 she awakened with
severe nasal catarrh, sore throat, intense headache,
and what is vaguely spoken of as congestion of the
liver. The headache was soon better, but vomiting
set in anew, and on May 2d became persistent and
inexorable. The region of the liver and epigastrium
was throughout intensely sore, and the surface of
the abdomen exquisitely hypereesthetic. From this
time all food, save twice a little dry toast (an inch or
two), was refused. I am told that she swallowed
no food save this until June 16 — a fast of forty-five
days. Water she took in small amounts, but always
it instantly provoked regurgitation. During this
time her menstrual flow returned, and then amidst
a storm of pain and cramps, with general hyperaes-
thesia of skin, ceased, to return no more for months.

The evidence as to this amazing fast is, as far as I
can judge, complete. Her mother, a woman of

20

230 DISEASES OF THE NERVOUS SYSTEM.

vigorous character, was the sole nurse, and rarely
left her. The assisting care was by relatives, and
was methodical and accurate. The physician who
watched her case was a very able man. I^or, despite
my skepticism, have I been able to find fault with
the evidence. Her own state of exhaustion, the
vomiting, dry tongue, fever, and cramps, forbade the
belief in deception as possible, even had she been
ever left alone for a moment.

About June 14 the tendency to anuria developed
into a complete expression of this symptom, followed
after twenty-four hours of suppression by a scanty
flow of bloody urine with epithelial and renal casts.
The exhaustion was now extreme. Her vision
became doubled, articulation impaired, breathing
labored, and her memory failed rapidly. Tempera-
ture 99.5° to 102° F.; pulse 120 to 140. Then food
was given by enema.^ A little barley-water was
retained on the stomach, and there was a general
betterment until June 26, when the urine was again
scant and bloody. About this time she became un-
conscious, the strabismus was more marked, and her
loss of voice entire. Involuntary escape of urine
and feces took place. At times there was muttering
delirium, or else her head cleared a little and her
voice became distinct only to prove that all memory
of past events seemed to have been lost. The nausea
meanwhile ceased, but food was taken only in small
amounts because of the impaired deglutition.

1 Before this, in the early stage of the fast, an enema was used,
but not repeated owing to the convulsion it caused.

ORGANIC DISEASE OF THE SPINE. 231

By slow degrees she became better. The bowels
acted more comfortably, the urine grew clear and
lost its albumen; some food was desired, and the
intervals of sanity were longer and more frequent.

At this time a new set of symptoms arose. The
acute expressions of hysteria passed away, and, be-
coming more and more conscious, she began to
complain that her legs seemed to be too long and
were heavy, while quite rapidly both legs drew up,
bending to an extreme limit at the hip, knee, and
ankle, but not being also adducted strongly, as are
usually hysterically contracted legs. This change
was complete by August 16th, and was accompanied
with intolerable pains in all the limbs, but especially
in the feet, which were, however, insensible to touch
and to the pin-point. Meanwhile her other symptoms
grew less severe, her eyesight, which had seemed to
be quite lost, slightly improved, and her appetite,
digestion, and bowels became more manageable.
The pulse was still 120 to 180 : respiration 30 to 40;
temperature 99° to 100°. Intense surface hyperses-
thesia existed, and sleep for 2 to 4 hours a day was
won by the help of morphia and bromides. About
September 1st her voice returned and became full
and clear. Eemoval to the country September 5th
caused further gain, so that the pain lessened in her
arms. All the nutritive functions grew better, and
her sleep increased. Unfortunately, this gain soon
ceased, and the disabilities and suffering of the
legs became worse and worse, the mind remaining
feeble and the memory as I have described it.

She was finally brought to me in a state which

232 DISEASES OF THE NERVOUS SYSTEM.

filled me with despair, mingled with regret, that in
such a condition she should have made so long and
so useless a journey.

Indeed, the figure which lay before me on the
bed was not one to make a doctor hopeful of its
future.

When first I saw her the girl was lying in bed on
her side, with her legs flexed to the utmost, and her
knees drawn up almost to her chin. Her face was
ruddy, naturally, and was much flushed, but the
lips, gums, and conjunctiva were quite too pale.

The extraordinary dilatation of the pupils at once
arrested my attention, I never saw so large a pupil-
lary space. Without warning, I threatened the eyes
by a rapid motion, and saw that she was blind. She
could tell night from day, but could do no more.
The conjunctiva was sensitive. There was no stra-
bismus, and the eye-grounds were normal. She had
not menstruated since June.

Her feet were too numb to distinguish the points
at any distance, and she felt neither touch nor needle-
pricks below the ankles. If I moved the foot she
felt it, but was not always sure as to the limb han-
dled. Passive motion of the toes was unfelt. Above
the knees the feeling in all forms was better, and
was nearly normal in the hands.

Of late the pain in her feet had become atrocious,
and especially was this so at night, whence her sleep
was becoming less and less deep, so that often whole
nights of extreme pain were endured without sleep.
This pain was an ache of the feet, and more of the
left foot. Otherwise, except a nearly constant head-

ORGANIC DISEASE OF THE SPINE. 233

ache, there was no pain. Passive efforts to straighten
the legs occasioned unbearable pain. That this was
not the simple contracture of hysteria was shown
by the failure of these muscles to relax at all under
* complete anaesthesia. Moreover, about the tendo
Achillis and in the popliteal spaces in both legs,
there was a brawny deposit which seemed to be in
the areola and about the tendons. The feet were
cold in the day-time, slightly oedematous, and apt to
be hot and red at night.

The muscles and nerves of the left leg gave all
the ordinary reactions of degeneration, those of the
right side being less complete. The interosteal
groups of the left foot failed to respond to all excita-
tions. Above the knees the left thigh muscles,
anterior groups, showed quantitative diminution of
reactions.

Owing to Miss B.'s weakness and to the con-
tracted state of the limbs, she usually remained on
her left side or on her back supported by pillows.
The loss of vision, the vast pupils, the lack of
memory, and the lessened power to think, combined
to give to her face a vacant though gentle and
childish expression. All efforts to raise her even
to a sitting posture resulted in such violent vertigo
as to discourage any renewed attempts.

The knee jerk was absent on the left and lessened
on the right side. The secretions were normal, and
the urine free from albumen.

It seemed to me improbable that all the phe-
nomena of this sad case could be referable to hys-
teria. But it also appeared to me impossible out of

20*

234 DISEASES OF THE NERVOUS SYSTEM.

this complexity of symptoms to select those which
were essentially due to former ursemia, to possible
disease of the spine, or to mere functional nervous
troubles. A careful blood count showed the pres-
ence of decided ansemic conditions, and accordingly *
lactate of iron was henceforth used steadily in full
doses.

The horrible pain in the feet was destroying sleep,
making sedatives necessary, and seemed to demand
most attention. For this I ordered alternates of ice
and heat to the feet thrice a day, massage, and
faradic electricity, whilst an attempt was made to
straighten the legs by a Stromeyer splint, which only
increased the pain, and was abandoned. In a fort-
night the calf muscles began to respond to the faradic
battery and the hardness about the knees and ankles
lessened so decidedly that soon after I determined,
on consultation with Dr. W. W. Keen, to have the
tendons cut and to extend the limbs. Accordingly
on December 5th and 8th, Dr. Keen divided the
tense tendons at the groin, knee, and ankle in two
operations, and with unusual difficulty extended the
limbs upon splints. There was not the least relaxa-
tion from-the fullest use of ether, and so great was
the force needed to straighten the legs that we
dreaded lest some rupture of nerve or artery might
occur. As it was, the skin beneath one knee cracked
a little despite all our care. Certainly the relief
thus given was abrupt and nearly complete, so that
in a day or two after the last section all narcotics
were laid aside. Whether this grateful change was
due to extreme stretching of nerves long imprisoned

ORGANIC DISEASE OF THE SPINE. 235

in hardened tissues or not, I am unable to say.
The operation caused in the feet great tingling and
numbness which soon passed away, and a rapid gain
in power, feeling, and nutrition followed.

In a few days she was at times placed on a board,
and so secured by straps that she could be raised
inch by inch thrice a day. At first this caused
vertigo and faintness, and choking sensations, with
soreness of the long unused feet. Meanwhile gen-
eral massage, electricity, and frequent feeding were
kept up. As soon as she could bear to stand, she
was trained to kneel, and at last to creep sustained
by a sheet held by the nurse, in the manner already
described. Then she learned to use crutches, and
finally the crutch canes.

Meanwhile her sight came back by degrees, and on
February 1st she could write a few words and read
a page of large print. The pupils were no longer
dilated. She walked quite well on the cane crutches.
Menstruation returned January 1st, and was hence-
forward regular, but for three months was preceded
by slight delusions, as to having heard conversations
she had not heard, and by great nervousness. On
February 16th she stood alone without crutches. She
had during all this time the most remarkable difla-
culty in coordinating her movements. The effort to
redress her lost balance at any moment seemed to
result in a momentary delay, so that the needed act
did not occur soon enough, and thus she swayed to
and fro, but after February 5th did not fall. By de-
grees her efforts grew to be more effectual, and her
nervousness and fits of depression less and less fre-

236 DISEASES OF THE NERVOUS SYSTEM.

quent. With her eyes shut she could neither stand
nor kneel erect, but by practising blindfolded she
rapidly acquired better power to stand and to kneel
with open eyes.

March 2d she walked well on crutches unaided,
and drove out. March 10th she came to my house.
I found then no eye-ground lesions, but observed
with the ophthalmoscope, what often escapes obser-
vation without it, that she had a slight but constant
lateral nystagmus. Vision was normal. Her mind
during all of this time improved steadily, and it was
most interesting to watch the gradual restoration of
her memory of past events, and of what she had
learned at school. When she went home, March
13th, her power to recall recent events was still bad,
but it also returned within a few months, during
which her whole progress was rapid, and at last
restored her to absolutely perfect use of mind and
body.

Let us look back over this long statement. This
young woman, amidst a confusing storm of hys-
terical symptoms, had contraction of the legs, which
had lasted but a few months, but which did not yield
in the least under the most complete ansesthetization.
The muscular interspaces were glued together with
a brawn-like material, especially back of the knees,
as I have seen in some cases of general myelitis.
The electrical reactions were those of degeneration ;
the reflex arc was broken. There was motor and
sensory paralysis. It is difficult to escape from the
conviction that we had here a diseased spinal cord,
whilst the readiness and the completeness of the

ORGANIC DISEASE OF THE SPINE. 237

cure cannot but cast some doubt on this conclu-
sion.

This, with some other cases which I may detail
in future, has led me to the belief that organic
maladies occurring in profoundly hysterical people
do not always present exactly the same types as exist
in patients not hysterical. Otherwise how shall we
account for the remarkable cure of this case, and for
the utter disappearance of all of those evidences of
local myelitis which we usually regard as ending for
the patient all hope of an active life ? The clinical
history of acute disease in hysteria is yet to be
written ; but even were it completed, such cases as
I have given must continue to puzzle us until we
know more — and we now know nothing of what
constitutes the physical basis of the disorder we call
hysteria.

238 DISEASES OF THE NERVOUS SYSTEM.

LECTURE XV.

GASTEO-INTESTINAL DISOKDERS OF HYSTERIA.

I HAVE said in these lectures very little as to the
gravest of hysterical symptoms — the persistent hys-
tero-epilepsies, and the multiple and severe contrac-
tions which Charcot and others describe. I have said
little because, in my experience, and it has been very
great, these terrible cases are rare in America in any
class of life, and most uncommon in the lower classes,
among which Charcot seems to have found his worst
and most interesting cases. In this disorder, as in
chorea and many other diseases, there is, I suspect,
some difference between this country and Europe.

My own clinic furnishes yearly hundreds of cases
of neural maladies, but while I often see examples of
every type of the milder forms of hysteria, it is ex-
tremely uncommon to encounter the more severe
and lasting forms of the disease.

My friend, Dr. C. K. Mills, w^ho has charge of the
extensive out-wards for incurables at the Philadel-
phia Hospital, writes me that his experience is simi-
lar to mine. He says : " My wards contain some
cases of hysteria of long duration, but they are not
numerous. As the result of some experience, both
in and out of hospitals, I have come to the conclusion
that cases of grave hysteria, such as the hystero-epi-

GASTRO-INTESTINAL DISORDERS. 239

lepsies of Charcot, are rare in this city and country.
Spasmodic disorders, associated with hysteria, do not
seem to me to be as frequent here as abroad. Hys-
terical palsies are more often met with. Il^euralgia,
spinal irritation, ovarian hyperse-sthesia, and special
forms of mental and moral perversion are, in my
experience, the more usual forms of American hys-
teria." It is impossible to acquire as to a matter like
this precise statistical information, but from what I
know of the experience of other physicians in l^ew
York, Boston, Baltimore, and Chicago, there is every
reason to believe that it does not differ from the
views entertained by Dr. Mills and myself. The
causes of this difference in the symptom-products of
a disease so common, and which finds in all lands
and all female human nature enough conditions
favorable to its growth, would be a somewhat inter-
esting inquiry, but one for which I must confess there
is yet wanting satisfactory material.

I have given in the final lecture of this volume
some general directions as to the treatment of ex-
treme cases of malnutrition and hysteria. I would
like to make here some remarks as to the especial
difficulties which meet us in connection with the
stomach and bowels of hysterical w^omen. N^o
matter whether we treat them, as is preferable, by
exercise and baths and change of air and tonics, or
are driven in despair to the more unnatural treat-
ment by seclusion and rest, we have still in all cases
to feed them, and in all to see that the bowels are
kept reasonably open. The lighter cases of hysteria
which come afoot to my clinic can give you no idea

240 DISEASES OF THE N-EEVOUS SYSTEM.

of the gigantic, almost grotesque, proportions which
symptoms may assume in the graver cases of hys-
teria, but in each and all it is usually some trick
of the stomach or gastro-intestinal tract which soon
or late baffles or perplexes us. In one case you
have an apparent inability to chew; food rests in
the mouth until helplessly removed by a nurse or is
half passively let fall out by the patient. I have
such a case now. I had to begin by admitting an
interest in her failures and advising her to move the
jaw with the hands, which she did do for a while
until the power or the belief in the power to chew
came back.

Next comes the oesophagus with its troubles — at
times a spasm, at times a paralytic state, more rarely
a pharyngeal anaesthesia — but in each case attention
to the act of swallowing helps to embarrass it.
This diffi.eulty may come on abruptly and be for a
time the only notable hysterical symptom. The
most common form of pharyngeal trouble is dis-
ability to swallow solid food. The patient's throat
behaves to every solid or semi-solid morsel as in
many well people the throat does to a pill. The
contact seems to irritate the mucous surface unduly,
and in place of the usual normal muscular reflex,
there is a mutinous response on the part of the
pharynx, and, as the patient tells you, the morsel
will not go down. There are other people whose
food meets with no difficulty in the pharynx, but
encounters below this region muscular spasm, which
drives it up again, either quietly or with violeuce,
and sometimes this trouble is only encountered at

GASTRO-INTESTINAL DISORDERS. 241

the lowest part of the oesophagus. These forms of
dysphagia — these varieties of cesophageal regurgita-
tion— are apt enough, soon or late, to involve the
stomach in a similar habit.

Gagging is a symptom with protective values at
times, and, like voice failure, is so near to a normal
product of emotion that its exaggeration in the
nervous is not to be wondered at. In such persons
it may be readily fostered into a troublesome habit.
I have seen several cases in lads and some in men.
In one instance, every novel social effort or expe-
rience causes regurgitation or diarrhoea, or both, so
that life has become a burden to the victim of this
curious neurosis.

You will be well off if you escape these exasper-
ating disorders in your early hysterical cases. They
are apt to be enduring and difficult of relief. I think
it curious that dysphagia should be so rare in old
hysteric cases. There are symptoms which are rela-
tively common early in cases, others which are seen
later, and are apt to last. Dysphagia one sees very
often in cases which are afoot.

If we fail of this annoyance, we may have to meet
certain gastric disorders. One is loss of appetite,
anorexia ; the other is vomiting. Of this latter
symptom I have already said something in a former
lecture. What I now refer to is the simple regurgi-
tation which we meet with in these cases. There is
no nausea — certainly after a while none — but the
food is returned to the outer air with a gulp, and
often with remarkable and painless ease.

You may think this sounds like a rather mild

21

242 DISEASES OF THE NERVOUS SYSTEM.

malady ; but in reality it is one of the symptoms
which, while it ma}^ haunt any stage of hysteria, is
of all symptoms except multiple contractions the
most enduring. I can recall a number of bed- ridden
cases of hysteria which have lasted from fifteen to
twenty-five years, and which are in the habit of
vomiting every meal ; and have done this for years.
One has actually grown stout under this ; but she is
an opium-taker, and rest with opium greatly aids the
storing up of unwholesome fat. The others are at
least not greatly wasted, and you ask yourself in vain
how they live upon the small quantity of food they
seem to retain.

We are apt, however, to forget how small is the
amount on which a person can live if at entire rest
a-bed. Then, also, the act of regurgitation is not
immediate upon the entry of food to the stomach;
nor, as 1 know from careful inspections, do these in-
valids vomit more than a part of what they swallow.

I put aside for the time the symptom loss of appe-
tite, because of all of the minor hysterical embar-
rassments we meet with, this is the worst.^ To call
this loss of appetite, anorexia, but feebly characterizes
the symptom. It is rather an annihilation of appe-
tite, a lack so complete that it seems in some cases
impossible ever to eat again. Out of it grows an
antagonism to food, which results at last and in its
worst forms in spasms on the approach of food, and
thus in turn gives rise to some of those remarkable
cases of survival for long periods without food, which

1 Sir Wm. Gull. Trans. Clin. Soc, vol. vii. p. 22.

GASTRO-INTESTINAL DISORDERS. 243

you need not confound with the more or less suc-
cessful efforts to deceive by the pretence of fasting.
You will have constantly to deal with the various
grades of this disorder, if you are called upon to
treat hysteria. When it is merely failure of appe-
tite, you may disregard it as you would the anorexia
of fever, no matter how extreme it may be, and in-
deed the more so because it is extreme. There are
some useful hints which you may keep in mind for
these contingencies. Fluids can be taken when
solids are inhibited by the disgust they cause, but,
as regards solids themselves, if they be finely divided
or put in a fluid as mincemeat in soup or rice in
milk, they are sometimes taken w^ell, whilst if alone
they would be rejected. I may also add that if the
patient be in bed you will often be able to give
solids, if the nurse herself feeds the patient, since
then you get rid of at least one volitional act, and
the added chance for deliberation, and consequent
disgust which it affords ; nor is it wise to delay rectal
feeding, as it is apt to be delayed.

Sometimes this symptom exists only at the men-
strual period, or is then greatly intensified, and, as
at this time the consequences due to loss of blood
are in feeble women made worse by failure to eat,
one of the most valuable lessons you can teach such
women is the absolute need to eat, or, at least, to
drink nutritive food, whether it be agreeable or not.
The graver cases of self-starvation which arise out
of the superlative degree of hysterical dislike of food
are far more serious. They result, as I have said,
in the patient refusing all food, and sometimes before

244 DISEASES OF THE NERVOUS SYSTEM.

such cases the utmost skill and the largest experience
are simply impotent. Few of these cases exist with-
out there being a certain amount of doubt as to
whether or not the supposed fasts thus brought
about are really fasts, yet, as regards some of them,
there can, I think, be no doubt.^

I have seen several instances of excessive fasting,
and I propose now, in addition to that already inci-
dentall}^ described, to call your attention to two
others which possess peculiar interest. The first
one I studied with extreme care and with every pos-
sible advantage ; the second came to me long after
the time of fasting had passed, and although a
woman to all appearances hopelessly hysterical,
completely recovered. Her fast was observed by
physicians as competent as Charcot and Brown-
Sequard, and of it I have a very good history :

Miss L. C, set. now 38 years, had in her 18th year
an unhappy love affair, and soon afterwards a fall in
which she struck her back. Within a few weeks
intense spinal irritation set in, for which braces and
corsets were used, and, these failing, rest in bed was
prescribed. The latter remedy was a fatal one, and
she has never since left the bed to which a physi-
cian's orders sent her. It were tedious and useless
to dwell on the wild variety of symptoms which fol-
lowed, as we are dealing now with only one of them.
Hysterical paralyses, anaesthesias, ischuria, anuria,
polyuria, hyper?esthesias of skin, ej^es, and ears, suc-
ceeded one another singly or in perplexing groups.

1 See case in the last lecture.

GASTKO-INTESTINAL DISORDERS. 245

A year or more before I first saw her, contractions
of the two legs and feet began, and went on from
bad to worse ; while both legs to the waist were in-
sensible to pain and changing temperatures, but still
appreciated the position of a touch quite fairly well.
The body was excessively wasted, the skin dry and
sallow, and covered with bran-like scales of epithe-
lium. About the sixth year of her disorder she
began to have a constipation so obstinate that neither
drugs nor mechanical aid was of the slightest use,
and from this time for years the bowels were moved
but once a month, at which time there were violent
attacks of hystero-epilepsy. At or near the time
when this difficulty developed itself fully, she ceased
to pass water more than once a day. With the help
of careful nurses, I was able to study this curious
symptom which in her assumed an unusual form.
During thirty-nine days her urine reached a daily
average of three ounces. The specific gravity was
1040 to 1060. It was dark, and clouded with urates
and crystals of oxalates and uric acid. The pulse
rose to 120 ; the respirations to 60 or 70 ; and in
place of the usual vomiting, which Charcot has
studied so admirably, and which he has shown to be
vicarious and charged with urea, profuse sweats
broke out, and left the skin covered with a white
film in which I found large quantities of urea. Then
the scene changed, and about the thirty-ninth day
the sweats ceased, violent vomiting with nausea fol-
lowed, and she began to drink vast quantities of
water, which seemed to be absorbed with great
speed, since the vomiting which took place at inter-

21*

246 DISEASES OF THE NERVOUS SYSTEM.

vals was merely of a thick, slimy mucus. At the
same time the anuria ceased, and, from passing some
days no urine at all, she poured forth large amounts
of limpid water, sp. gr. 1005 to 1012.

The fluid thus secreted averaged, for ten days, five
to ten quarts ; but the amount swallowed was equal
or more in amount. By degrees this sj^mptom faded
away, and she drank less and less, and ate almost
nothing; until, at the close of another month, the
urine growing smaller in quantity, she ceased to
vomit, except when urged to take food. Her condi-
tion was then as follows : She passed six to ten
ounces of urine daily, and drank, by the teaspoon,
about twelve to fourteen ounces of water. She took
no food at all for ten days, and then but a few tea-
spoonfuls of milk, which always caused vomiting.
From this time twenty days passed, during which
she took no food, but had fifty to eighty drops of
laudanum daily, which she never vomited. Her eyes
remained closed, the least vibration or light caused
agonizing cries, and every one expected to see her
die at any moment. Efforts at rectal feeding or in-
unction of oils gave rise to horrible spasms, and in
this condition day after day went by. The watch
over her was rigid and faithful, and every effort even
to give a teaspoonful of fluid was carefully noted. I
am as sure as I can be of anything that in one month
and -Q.ve days she never took in all more than twenty-
four ounces of milk, and the amount of water I have
mentioned. Whether this almost incredible absti-
nence was aided by the large quantity of opium
taken is, at least, difficult to say. There were,

GASTRO-INTESTINAL DISORDERS. 247

during the time in question, a large number of hys-
terical spasms, but, with this exception, the patient
lay almost motionless. ISTow, as yet, we quite lack
material for the determination of the nutritive needs
of a body at absolute rest ; so that it is hard to decide
how much is needed for the mere sustenance of neces-
sary function. I have seen a woman, weighing one
hundred pounds, remain at rest in bed, and lose no
weight in ten days on a diet of one pint of good milk
daily.

Certainly my patient lost weight. At the close of
her fast, when she began to take and retain milk in
small portions, she was wasted almost to the last
degree, and this has never failed to happen in such
experiences as I have had of true fasting. This
woman had in all three periods of abstinence, but
the one I have described was by far the longest.
The contractions have of late years become more
and more extreme, and, as they have increased, the
anaesthesia has become less, while the electro-mus-
cular excitability of the leg-muscles has lessened.
I have little doubt that the lateral columns of the
cord are now in a state of advanced sclerosis.

The second case of fasting was also one of extreme
interest, because abstinence was one of the series of
most interesting phenomena, covering some ^^ears ;
and resulting, finally, in a nearly complete restora-
tion to health.

Miss L., of Connecticut, set. now 28 years, went
abroad after having suffered a long and severe
strain on her emotions and sympathies; a strain
which did not lessen, but from which she fled in de-

248 DISEASES OF THE NERVOUS SYSTEM.

spair. The results were broken sleep, great, though
suppressed, nervousness, but no notable functional
disturbances. To keep down this sensation of
nervous excitement she was accustomed to walk
for hours, returning home with increasing pain and
tenderness of the spine, the back of the head, and
the scalp in general. The symptoms were thought
grave, and were at last treated by a long blister over
the spine. On removal of the blister there was a
furious outbreak of weeping, general convulsions,
and incessant local spasms of the extremities, which
nothino^ checked or lessened. These conditions
lasted during February and March, and were made
worse by a large crop of carbuncular boils, which
formed on the part where the blister had been
placed. About this time, despite the sagacious care
of excellent physicians, she began to eat less and
less, and at last, early in April, ceased to eat at all.
Exaggerated hiccough set in, furious convulsions
arose at every effort to feed her, and these symptoms
repeated themselves six or seven times a day, some-
times without any apparent cause. Rectal feeding
was given up, because it also gave rise to spasms,
and there seemed nothing to do but to wait. For
twenty-seven days neither liquid nor solid was
swallowed. The tongue became black and dry, and
cracked; the lips were thin, and crusted like the
teeth with sordes and blood; the breath foul; the
eye sunken ; respiration quick and labored ; the
pulse 120 to 130 ; and speech whispered and diffi-
cult. Meanwhile, all convulsive acts ceased, and
her mind seemed at times quite clear and capable.

GASTRO-INTESTINAL DISORDERS. 249

Twice her physicians were called in to see her die;
but the stupor, which seenied almost as deep as
death, also, in its turn, passed away.

I am unable to give details as to the state of the
secretions during all of this long fast. The bowels
were, I think, moved once, and the urine ceased to
be secreted after the eio-hteenth dav.

There was some difference of sentiment in the
consultation brought about by this grave condition,
one great authority advising inaction until nature
asked for food, wdiich he thought would happen.
Another physician, who was then consulted, saw in
her case an example of starvation which, having
reached the line of great peril, demanded forced
feeding by the stomach tube. I am positively in-
formed that of this counsel, which it was resolved
to follow, the patient knew nothing. However, at
this critical moment she motioned to her physician,
and in a whisper said she could now take food.
Then came two weeks of careful spoon-feeding,
with constant threats of repeating the old troubles,
when, suddenly, a general tremor set in, and the
motion growing larger, became twitching, and so
by a crescendo movement went on into violent con-
vulsive acts, until, despite the care of those about
her, she was thrown by a series of spasms from the
bed to the floor, where she lay, muffled with shawls,
cloaks, and pillows, to save her from bruising her-
self. At length chloroform brought quiet. The
summer wore away with a variety of symptoms,
such as partial palsies, aphonia, and mental depres-
sion. The next autumn she was removed to Liver-

260 DISEASES OF THE NERVOUS SYSTEM.

pool, and there during the winter she had variable
degrees of anorexia, and the usual miserable variety
of hysterical disorders. Treatment was varied
enough, but always unavailing, because no treat-
ment could ignore food, and that was kept at the
minimum on which existence is possible. Early in
the next September the girl mustered courage to
cross the Atlantic, and arrived in E'ew York, suffer-
ing with a loud, incessant cough, which brought up
strange quantities of glairy mucus. Emaciated to
the last degree, with evening fever and morning
chills, she seemed on the verge of death, when
almost suddenly the cough ceased, and the starva-
tion symptoms reappeared, but not in so disastrous
a shape as had marked their appearance in Paris.
After a partially successful treatment at the hands
of her physician in New York, circumstances re-
moved her from his care. Again the stomach tube
was advised and declined by the family, and again
days passed without food, while the convulsions, the
wasting, the black tongue, the breath, Avhich Brown-
Sequard had described as an odor like that of altered
fusel oil, and the shrunken belly, all promised a new
period of three weeks' fasting. It proved, however,
less complete than before, and she gradually rallied.
From this time she remained in bed for nine months,
eating little and irregularly, a wretched invalid, not
very thin, but not fat, with occasional spasms, great
nervousness, distressed by light, by sounds, by any
company which was not quite agreeable, forever
alarming her friends by threatenings of a repetition
of her former troubles. I somewhat reluctantly

GASTRO-INTESTINAL DISORDERS. 251

took charge of this lady early in the following
spring. The most absolute seclusion and the use
of skiramed-milk diet, aided by massage, slowly
triumphed over her disorder, and by and by she
regained control over her too emotional tendencies,
and was restored to a state of health unknown to
her for years.

252 DISEASES OF THE NEEVOUS SYSTEM.

LECTURE XYI.

THE KECTUM AND DEFECATION IN HYSTERIA.

You will find among hysterical and also among
merely feeble people several forms of difficulty asso-
ciated with the function of defecation. One which
is not uncommon is a feeling of great weakness
after every movement of the bowels. This some-
times goes so far that the patient will show clearly
enough, in the pallor and the hastened heart, how
real is the sudden enfeeblement thus produced. In
still less common cases the patient faints after the
stool is passed, and is especially apt to do so if the
evacuation be loose and therefore sudden. I know
of one man in quite fair health who is never without
a sense of faintness at and after a passage, w^hile a
stool at all watery is sure to cause him to faint.

iTaturally enough, such phenomena are frequent
in the class of cases w^e are now considering — so
that it is sometimes needful to give a little stimulus
before the evacuation occurs, and also to insist on
the use of a bed-pan. If you can thus break up a
morbid habit, or at least make this occurrence of
faintness unlikely for awhile, the gradual return to
full health, which, meanwhile, you are in other
ways promoting, will take care of the future.

There are other and more formidable expressions

EECTUM AND DEFECATION IN HYSTERIA. 253

of hysteria in connection with the intestinal func-
tions. I bring before you to-day a case which typi-
cally represents one of these difficulties.

The patient, a young married woman, aged 29 ;
has had two children. She ascribes her present
troubles to the pressure of a retroverted womb on
the rectum since the birth of her last infant. She
has worn many pessaries, and undoubtedly once did
have retroversion of the uterus. To-day she has a
slightly eroded os uteri, normal menstruation, and,
if any displacement, a womb slightly anteverted.

Unhappily she has been told that the womb press-
ing on the rectum interferes with the downward
passage of the feces. It once, as she explains,
caused constipation, but now, owing to the long
continuance of the malposition, it causes " irrita-
tion," in consequence of which she has the disorder
out of which I shall make a text for this lesson.

She says she has diarrhoea, and tells me that be-
fore and during her menstrual flow she has six to
twenty operations a day. This is quite true, and
for a short time I accepted as correct the idea that
she had diarrhoea, for when any one says she has
twenty movements daily we are too apt, as a rule,
to think of them at once as being necessarily loose.
But on further study of her case, I soon learned that
the single stools were never other than very small
and quite natural or constipated. The moderate
amount of fecal matter which commonly rests quiet
in the bowel until accumulation stimulates the in-
testines to action, in her at once caused enough
excitation to give rise to a discharge. As this went

22

254 DISEASES OF THE NERVOUS SYSTEM.

on all day, and even at night, it seemed, at times,
and especially towards bed-time, to give rise to irri-
tated states of the mucous membrane, so that there
was sometimes pain and a discharge of shreds of
mucus, as to which much was said by the patient,
who carefully examined every passage.

This was a perfectly typical example of the ex-
citable rectum due to hysteria, and precisely like
the irritable bladder which we find in similar cases,
and which is so exasperating a symptom, or, again,
like the eraesis of hysteria, or the hysterical cough.

This form of rectal trouble is not very uncommon.
I have seen it thrice this winter ; but then it is to
be remembered that I see much hysteria. I may
recall, in passing, that I have encountered the same
form of trouble in men. The present case has been
carefully studied, and I am able to exclude all possi-
bility of any organic trouble. On the other hand,
she has had several times rigidity of all the limbs
during certain attacks which she calls distresses in
the head and spine, and assures me are not painful.
In fact, she has the face, the ways, and the habits,
and even the vagueness, of some hysterical women,
so that when she describes this rectal disorder I at
once recognize it as a familiar puzzle of well-known
parentage.

You may see the excitable rectum as a mild symp-
tom at the menstrual time, or brought on by emotion,
or you may observe it in horribly exaggerated forms,
so that it becomes the dominant feature of the case,
or it may be disagreeably associated with a like state
of the bladder.

RECTUM AND DEFECATION IN HYSTERIA. 255

I recall one relentless case of this double disorder
which had suffered with the " fearful joy " of hys-
teria under the examinations of I cannot tell how
many surgeons — English, French, and American.
This young person had had a disappointment in a
love affair, five years before I saw her. It caused
hysterical anorexia, and at last stomachal regurgi-
tation, which got well a year before she came back
to America, and while at St. Moritz. Then, by
degrees, without known cause, arose an irritation of
the rectum and the bladder, which had become ex-
treme when she consulted me. She was rosy, well
nourished, ate well, walked well, and slept between
the times of discharges. These were said by her
to occur at least every half hour, as concerned the
rectum. Each time there were merely one or two
small scybala expelled, as she said, with violence.
Her nurse believed that the discharges took place
at least every hour, and that the bladder was dis-
turbed almost incessantly, certainly thirty to fifty
times a day. ^Nevertheless the rectum was healthy,
the bladder normal, the urine ideally wholesome,
and the young person affected, delightfully in-
terested in my study of her case.

I have known the irritation of rectum to go so far
as that the victim wore a bandage and towel, insist-
ing that at any moment she might be surprised by a
passage. The successful treatment of such cases is
sometimes easy, sometimes very difiicult. If the suf-
ferer be really ill, and has to be treated for some form
of malnutrition, you may be so fortunate as to see the
irritable rectum getting well as the other symptoms

256 DISEASES OF THE NEKVOUS SYSTEM.

of hysteria fade away. But suppose you find the
patient better in all ways but this one, or that this
annoyance is the single sign of a condition not other-
wise notable, what can be done to relieve it ?

If the patient be intelligent, you should first try
to make plain to her that her disorder is a habit, and
not a disease; that it arose on slight provocation,
was yielded to, and so at last became despotic. Con-
vince her that she can again remake the habit of
infrequent discharges, and then, if she be resolute
and will obstinately fight the symptoms, she ought
to get well. She may be assisted for a time by
occasional aperients, and better by a daily and com-
plete washing out of the bowel with an enema of
water, so as to remove as completely as possible, all
the feces; but explain to her that this is merely a help,
and that her own will is the only permanent and
efficient aid to which she can look. In cases where
the symptom was temporary or of recent birth, I
have used opium in suppositories, but not in others,
nor is it necessary or, as a rule, desirable. In sharp
contrast with the too irritable rectum, prone to re-
sent the presence of the smallest amount of fecal
matter, is the still more annoying condition of
deficient activity sometimes to be met with.

The paretic or the paralyzed rectum, for its inert-
ness becomes that of a local palsy in some cases, is a
symptom once met at its worst never to be forgotten.

At some time in the progress of a case of grave
hysteria we are apt to have to deal with it. The
upper intestines do not usually share in the difficulty,
and this IS a very interesting fact. However we may

RECTUM AND DEFECATION" IN HYSTERIA. 257

explain it, the food does not come away undigested
or half digested. The accumulation is that of fecal
matter fully formed and resting either in the whole
lower half of the descending colon all the way to
the anus, or else is merely a collection in the sigmoid
flexure. For some reason the feces fill up more or
less of the intestine, and there remain. The diffi-
culty arises from one of three causes, and sometimes
from a combination of all in varying degrees. First
a woman disposed to humor her sjmiptoms and
make the most of them, becomes, from some cause,
costive, and ceasing to make any effort to be moved
at an habitual time, resorts to enemata in increas-
ing amounts, so as needlessly to dilate and thus
to weaken the bowel. Aided by the want of will,
and made worse by inattention, or by the desire to
exaggerate and foster a symptom thought of moment
by others, the evil grows from bad to worse, until
she gets a fissure or hemorrhoids, when the pain
caused by costive movements adds its inhibitory
influence. In all of this there is nothing essentially
hysterical, yet, nevertheless, neglect of the function,
excessive use of enemata and of purges, are apt to
occur in the hysterical. Once the habit of inaction
is made, and has drawn attention, or pain from
fissure is superadded, we are apt to have the dis-
order assuming graver forms, and it may be sus-
pected that sometimes in severe cases in women of
hysterical type, distinct sensory or motor losses are
superadded. Such women get curious notions about
the cause of their constipation. Among these it is

not unusual to hear that the rectum has formed a

22*

258 DISEASES OF THE NERVOUS SYSTEM.

poucli in front, and that some manual support is
needed to prevent its increase and to assist the act
of extrusion. The graver forms of constipation in
hysteria are due to

A sensory paralysis of the rectum.

A loss of power in the rectal muscular walls.

A want of coordination of the various muscles
used in defecation.

A combination of two or of all of these factors.

In a few cases the rectum and the skin about the
sphincter are insensible, and do not feel a touch or
distinguish cold from heat, or exhibit any irrita-
bility in response to the increasing volume of accu-
mulating feces. The extent to which, under these
circumstances, when at their worst, filling up of the
bowel with feces can go, is something strange. I
still see, at intervals, a lady for many years a hys-
terical bedridden case, with contraction and atrophy
of the legs, who exhibits this difficulty in its most
remarkable form. For many years she has had the
bowels moved but once in four weeks. As the time
approaches the abdomen swells and becomes tender,
the large daily dose of opium is doubled, and at last
she takes four ounces of castor oil. As this reaches
the colon she is seized with violent pains, and me-
chanical means have to be used to dig out the lowest
of the feces, and then, amidst repeated use of ether
and of morphia, and with horrible hystero-epileptic
attacks, enormous masses of dry fecal matter and
quantities of mucus are expelled. Although me-
chanical aid is given with unusual care, and enemata
of oil and flaxseed abundantly employed, she is apt

KEOTUM AND UEFEOATION IN" HYSTERIA. 259

to have the rectal opening badly torn, whilst the
extreme and rigid flexion of her thighs and knees,
and the spasm of the adductors, add to the difficulties
of helping her, and assist to increase her torment.
There is now no anaesthesia and no analgesia. The
earlier paresis of the bowels must be referred to a
date long past when there was remarkable general •
anaesthesia extending to the rectum and vagina, and
extreme indisposition to have movements of the
bowels because they were always accompanied with
a general convulsion. Hence arose by degrees, a
habit which has been cultivated to the horrible
extent I have described.

Paralysis of the rectum is rather rare in hysteria,
even in bad examples of paraplegia, but sometimes
it is seen almost alone as a symptom. In extreme
cases the rectum seems almost absolutely incapable
of being called into action by feces or enemata. A
hand may be carried with ease through the relaxed
sphincter and into the rectum, which yields readily,
all the accumulation being, as a rule, higher up.
These manoeuvres may or may not give pain ; at
the same time the battery has power to move the
fibres of the intestine and to act on the sphincter.
In one case this muscle was so flaccid that after a
passage the anus remained wide open for several
hours, as I have seen it in complete spinal palsy from
a rifle-shot.

In the two cases now in my mind there was no
loss of any of the ordinary forms of sensation.
About the anus or within the intestine heat, cold,
touch, and pain were duly felt, but no amount of

260 DISEASES OF THE NERVOUS SYSTEM.

stretching of the sphincter or intestine hurt the
patient. Yet freedom from pain is not the constant
rule in these accumulations, and, as in the case I
shall now relate, competent efforts to arouse to action
the inert mechanism used in defecation seem to be
a cause of horrible suffering.

If it happens to you, in an evil hour, to have one
of these cases to treat, with the additional need to
treat also the difficulties with which some tender
mother surrounds such a case, j^ou are much to be
pitied. T recall such an example, which I saw in
consultation some years ago. It began with a spot
of abdominal tenderness over the spleen. Pressure
on this caused nausea and vertigo. Then we had
convulsions, hysterics, coma, enormous polyuria,
and, at last, among other things, constipation. The
physician in charge gave me this list of the drugs
given in four days — night and morning, on each day,
an ounce of castor oil; at mid-day and bed-time one
drop of croton oil; three drops had been used in
one day. The more drugs she took the more she
demanded, and yet it was impossible to see that the
doses given caused pain. Meanwhile, for the nurse
and mother the arrangement for each evacuation
was the event of the day. A long stomach-tube
was carried six or seven inches up the bowel, and
half a pint of olive oil injected; then followed one
quart to three of flaxseed tea. During the use of
the enema one person was occupied in compressing
the anal opening so as to prevent the escape of fluid.
This help was made necessary on account of the
great relaxation of the sphincter, into which a thumb

KECTUM AND DEFECATION IN HYSTEKIA. 261

could be passed without any resistance which could
be felt to arise from a muscular act. Meanwhile,
the patient, Avhile insisting on the use of more water,
was shrieking with pain. The whole affair took two
to four hours, and the patient was, I thought, the
least exhausted of those concerned. Sometimes,
these efforts gave rise to a stool ; sometimes, there
was none for a week; and, sometimes under the
wild entreaties of the patient, these trying scenes
were repeated in the night, nurse and mother being
aroused to assist. I endeavored to get this girl out
of the control of her family, but I did not succeed ;
and I believe that her hysteria is now firmly estab-
lished.

Want of ability to coordinate the muscles is apt
to be associated with slight lack of power and more
or less anaesthesia, but instances of pure incoordi-
nation as a cause of constipation are very rare.

The muscles which in action are grouped to effect
defecation are the respiratory, abdominal, and peri-
neal, together with those of the intestine. Then it
is probable that as the act becomes imminent the
sphincter muscle may become somewhat relaxed so
as to make the matter easier.

Just such a combination of muscle acts is needful
for phonation, and you will recall my having de-
scribed cases which owed their aphonic states to
hysterical incoordination.

You may see like failures in defecation. The
bowels may be active, and the respiratory and ab-
dominal muscles fail to aid them. I have asked the
nurses to determine this for me, by placing a hand

262 DISEASES OF THE NERVOUS SYSTEM.

on the abdomen and inviting effort, or I have desired
this test to be applied at the time when effort is
natural. Sometimes they found either slight action
or unsustained action. In others, they found none,
and apparently, just as in phonetic failure, the
patient knew nothing of her defect, and although
surprised at having it made plain, did not seem
much better enabled to correct it.

Hysterical cases in which the extrusive muscles
act, but the anal opening declines to yield are most
rare. They naturally excite suspicion as to being
due to fissure, but none may be present, although
the sphincter may still contract violently when an
effort is made to dilate it from within by the feces,
or from without by the examining finger. There
is then a cramp-like pain which does not pass away
at once, and very persistent retention of feces.
Aperients cause pain but fail to act efiiciently, and
enemata are driven with violence through a nar-
rowed anal opening which ingeniously retains the
feces.

There are yet other rectal troubles which occur
in hysteria, and which come and go, are slight or
severe as the case may be. I refer to pain in the
rectum, and, of course, I mean pain where there is
no obvious lesion to account for it, no inflammation,
piles, or fissure. Your patient, if long enlisted in
the hysterical ranks, will be pretty sure to have some
theory as to this pain. It is a "tender ovary — tender
and much enlarged," or it is "congested," or a
" womb turned over backwards^ and blocking the
whole passage." I quote distinguished female au-

RECTUM AND DEFECATION IN HYSTERIA. 263

thorities. At all events, it is a pain descriptively
decorated with many adjectives. It may come on
with defecation or not. It may be described as
caused by sitting or walking. You look in vain for
a cause, and equally in vain for a means of relief.
l^ext to the irritable bladder of hysteria, this is the
most exasperating of all the minor miseries of this
disorder.

I have been reproached by a kindly critic or two
for not suggesting means of successful treatment
for all of the various forms of hysterical difficulties
I have described; but as regards some of them I
had little or nothing to say which was not already
well known, and this was most obvious and true as
concerns the management of hysterical disorders
of the rectum and bowels. Their treatment consists
in dealing with the case as a whole. To rely solely
upon medicines in such cases as I have described,
is, as a rule, useless, and I refer now, of course,
to examples of extreme constipation. In all of these
some good is to be hoped for from the use of induc-
tion-currents of electricity, one pole being used
within the rectum and one on the abdomen. In the
milder forms of hysterical constipation, I am apt to
order the well-known pill of aloes, strychnia, and
belladonna at each meal, and to cease to pay much
more attention to the bowels than is needed to avoid
such accumulations as may give rise to piles or
fissures.

As to rectal pain without lesion in hysteria, if I
can exclude the usual known causes of pain, I tell
the patient her pains will be well when she gets

264 DISEASES OF THE NERVOUS SYSTEM.

well, and then cease to allow them to be further
discussed.

The anal spasm may be relieved by moderate dila-
tation, which is preferable to section, since some-
times that too greatly and too persistently enfeebles
the sphincter, a most annoying result.

TREATMENT BY SECLUSION, REST, ETC 265

LECTURE XVII.

THE TEEATMENT OF OBSTINATE CASES OF NEE-
YOUS EXHAUSTION AND HYSTEEIA BY SECLU-
SION, EEST, MASSAGE, ELECTEICITY, AND FULL
FEEDING.

The lessons I have here gathered together would
be incomplete, were I not to add some more detailed
statement of my views as to the general treatment
of the conditions out of which arise the varied phe-
nomena of hysteria. Nothing, I think, can be more
melancholy than an honest survey of the amount of
good done in hysteria by the host of drugs which go
to form the so-called therapeutics of this disease.
In disorders where time is valuable we may find a
happy resource in the famous class of antispasmodics,
but as a rule they are swiftly disappearing from the
apothecary's prescription files, and the physician of
our day who is called upon to treat hysteria, or gen-
eral nervousness or neurasthenia, wisely contents
himself with a careful estimate of causes, and an
eflort to deal with these by patient treatment

Perhaps no cases are more common in general
practice, none more annoying, and none more
dreaded than those of hysteria, in its infinite num-
ber of forms and its infinite variety of masquerade.
The lighter troubles, the spasms, rigors, nervous-

23

266 DISEASES OF THE NERVOUS SYSTEM.

ness, and curious mental states, which haunt the
times of sexual changes in a woman's life, and espe-
cially her passage into womanhood, are more or less
easily dealt with. A careful study of the girl's char-
acter, of her home surroundings, of the incidents of
social life, which come with the development of pos-
sible passion, will be the best guide to treatment,
and with the obvious indications given us by distinct
physical ailments, local or general, constitute our
chief resources.

But besides these every-day manifestations of hys-
teria, we meet in practice with a growing class of
disorders in which change of social circumstances,
love affairs, disappointments, and what the French
call vies manqiiees, combine with physical accidents to
create invalids, who unite neurasthenic states with a
bewildering list of hysterical phenomena. These
are the '' bed cases," the broken-down and exhausted
women, the pests of many households, who constitute
the despair of physicians, and who furnish those an-
noying examples of despotic selfishness, which wreck
the constitutions of nurses and devoted relatives, and
in unconscious or half-conscious self-indulgence de-
stroy the comfort of every one about them.

These are the cases of chronic hysterical invalidism
which are so difiicult to deal with. There must bo
in every country thousands of these unhappy people.
They weary doctor after doctor, go hopelessly through
the various cures, and at last end in therapeutic
inactivity, or find a refuge in homoeopathy, which
promises a pill for every symptom, and leaves them
at last where it found them.

TEEATMENT BY SECLUSION, REST, ETC. 267

It is among such cases that we meet with the
strange and interesting disorders of which I have
said so much in these lectures — disorders which are
to be met, not by mere symptomatic therapeutics,
but by a full and clear comprehension of underlying
causes, and by such treatment of these, whether they
be moral or physical, as shall destroy the soil in which
hysteric phenomena flourish.

You will infer from these few introductory sen-
tences that I look upon most cases of confirmed hys-
teria as finally dependent on physical states or defects
which may first have been directly or indirectly due
to moral causes, or to these in conjunction with vari-
ously produced constitutional conditions. Ansemia
gives rise to lessened power of self-control, this to
emotional disturbances, and these, in turn, to loss of
appetite, out of which, if the surroundings be favor-
able, come graver nutritive disorder and endless
invalidism. This is a fair sketch of an every-day
occurrence. It would be waste of time to dilate on
matters so familiar.

In grouping cases of hysteria — and remember that
I speak now of the old and complicated and exasper-
ating forms of this disorder — there is one reservation
which I shall have to make, and but one. It refers to
the small group of women in whom we witness ob-
stinate hysteria associated with a nearly perfect state
of physical health. As I recall these cases they have
usually been women in middle life, and in easy cir-
cumstances. I know to-day of a dozen or so of such
people who are able to walk about and to do much
as they please; women in good condition, fat and
ruddy, with sound organs and good appetites, but

268 DISEASES OF THE NERVOUS SYSTEM.

ever complaining of pains and aches, and liable on
the least emotional disturbance to exhibit a quaint
variety of hysterical phenomena. For these women
there is usually no cure, and you will treat them in
vain.

We have, next, hysterical women who are well
enough to be able to correct the causes of their
disease by exercise and fresh air; and in this class
we find abundantly the cases of hysterical joints, and
all the range of mild hysteric and mimetic symptoms.
Once make sure that you have such people to deal
with, and common-sense hygiene, enforced by a reso-
lute will, and, when you have their confidence, some
earnestly given moral advice, will be the most they
will require. Let us put these aside, and we arrive
at the classes with an allusion to which I began this
lesson. They are the old and habitually bed- ridden,
or couch-loving invalids, who are to-day, as they
have long been, the despair of the best of us. What
shall we do with them ?

For practical purposes, we may divide them
coarsely into two sets : first, the nervous and hys-
terical woman, who is at the same time fat, but, as a
rule, ansemic. The class is not a large one, nor is its
anaemia very profound. As a rule, there is a look
about the fatness of these women which is anything
but reassuring. They are more or less feeble, not
large feeders, and prone to sufi'er from excessive tire
upon disproportionate exertion. I have elsewhere
discussed' at length the probability of there being

^ Fat and Blood. An essay on the Treatment of Neurasthenia
and some forms of Hysteria. Third edition, 1884.

TREATMENT BY SECLUSION, REST, ETC. 269

chemical differences between the fat of these and of
more healthy people. There is muscle and muscle,
fat and fat, and it is now become more and more
sure that these mysterious variations in the quality
of tissues, however little we may know of their chem-
istry, are such important factors in health that we
cannot at all afford to disregard them. I say all this,
because, when you meet with women who are at once
very stout, and not too notably ansemic, you may be
disposed to regard them too lightly as free from sus-
picion of any such grave nutritive disorders as may
seem to offer reasonable explanation of their nervous
symptoms. Those who are very plainly pallid and
flabby, fat and feeble, will, I may here say, offer, like
the rest of their class, a problem not always very
easy to solve. We shall, by and by, consider how
they are to be dealt with.

There remains, in the second place, the larger class
of nervous, and exhausted, and hysterical women
w^ho are, as a rule, weak, pallid, flabby, disfigured
by acne, or at least with rough and coarse skins;
poor eaters ; digesting ill ; incapable of exercise, and
suffering from the cold extremities which lack of
this, with thin blood, occasions. They lie in bed,
or on sofas, hopeless and helpless, and exhibit every
conceivable variety of hysteria.

It has been for some years my custom, when in
these women every other plan has failed^ to deal with
them by a certain combination of therapeutic means
which has now been securely tested by time and
hundreds of successes. It has stood the criticism
and won the approval of many competent physicians,

23*

270 DISEASES OF THE NERVOUS SYSTEM.

who have found in it a resource where all else had
failed. As it is now seven years since I first pub-
lished^ a formal statement of this method, it seems
to me that the time has come when I should say in
what respect my opinions have been altered or con-
firmed, and what changes I would desire to suggest.
I shall, therefore, give here a condensed statement of
the treatment in question, and referring to my for-
mer publications for minute details, shall criticise it
in the light of what, without want of modest state-
ment, I may venture to call an enormous experience.

The treatment to which in these pages I so many
times refer, consists in an effort to lift the health of
patients to a higher plane by the use of seclusion,
which cuts off" excitement and foolish sympathy; by
rest, so complete as to exclude all causes of tire ; by
massage, which substitutes passive exercise for exer-
tion; and by electrical muscular excitation, which
acts in a somewhat similar manner to massage, and
with it by depriving rest in bed of its essential evils,
leaves only its good. These means allow us to over-
feed our patients, and to enable them to digest with
ease large amounts of food.

I have here put first the idea of seclusion. That
means separation from indulgent friends and sympa-
thetic relatives. It is a change in the interest of
every one concerned, because a chronic invalid is a
slow poison in a household of loving people. It
means, too, the breaking up of old habits; and it
means, usually, a change of diet and personal sur-

1 Eest in the Treatment of Disease. Seguin series of Lectures.
Appleton & Co., New York. Fat and Blood, 1877.

TEEATMENT BY SECLUSION, REST, ETC. 271

roundings, because seclusion is not often to be at-
tained at home. For nervous or hysterical people it
must be absolute ; for merely feeble people, who re-
tain the power of self-control, and who are to be put
at rest, it admits of every degree of liberality. We
should remember, however, that even if a woman be
only a tired and weak invalid, and not a very ner-
vous one, she must, owing to the necessities of the
treatment, see daily the masseuse, the electrician,
the nurse, and the physician, so that to admit other
visitors is to make a needless call upon her growing
strength, which in these cases is sorely taxed by con-
versation. I do not say that seclusion is impossible
in the home of the invalid, for I have obtained it
with success many times, when my nurse was a thor-
oughly good one ; but the other plan of securing it
by a change of dwelling is better and far easier.
Seclusion, of course, has for its objects the cutting
off of many hurtful influences; but, above all, it
means the power of separating the invalid from
some willing slave, a mother or a sister, whose serf-
dom, as usual, degrades and destroys the despot,
while it ruins the slave. Like all rules, this latter
one of isolation from habitual personal relations,
has its exceptions. I have had cases nursed suc-
cessfully by a mother or a sister, but I never wish to
make the experiment, because it inevitably makes
heavier the doctor's task, and because it is nearly
always an experiment. G-et j^our patient alone with
a good nurse, with some woman who is trained, in-
telligent, young, and clever enough to read aloud,
and with culture enough to make her an agree-

272 DISEASES OF THE NERVOUS SYSTEM.

able companion. Ten j^ears ago there were few such
nurses; to-daj there are enough of them; but in
choosing a nurse, remember that if she has no tact,
or has a short temper, or is clumsy, or unueat, you
may have your case spoiled, or be forced to change
the nurse midway in your treatment; but, at all
events, never hesitate about this. If the patient
and nurse do not agree, make a change, and, if need
be, another. I cannot enough emphasize this matter
of the nurse. Put yourself in the place of an intel-
ligent lad}^ shut up for two months with a coarse
woman, whose talk and whose habits disgust, and
doubly disgust, because the victim is emotional and
sensitive b}^ nature and by habit, and you will realize
the need for care in your choice of an attendant. Mere
technical training will not answer, and I have seen
an utterly untrained woman, of good brains and tact,
win successes which are sometimes denied to the
best educated nurses who lack those ever-needed
moral qualities which no training and no length of
experience will give to some women.

And now, having your patient isolated and the
nurse in charge, certain grave questions arise. We
will presume that the case has been found to be
suitable, and that the patient has come within your
own control — whether at her home or elsewhere —
that her case is new to you, and that j^ou have de-
cided to use rest. The first question you will have
to settle is as to whether it be wise when using this
treatment to correct all womb troubles at once, or
to wait, or to neglect them altogether? I am guided
as to these matters by the following rules: In the

TEEATMENT BY SECLUSION, REST, ETC. 273

case of married women, I make or cause to be made
a thorough examination to begin with. If there be
onlj congestive states and their consequences, I trust
to the general treatment for cure. If there be
marked displacements or excessive menstruation, I
like to correct the one and have the uterus well
searched for possible causes of the other. Should
there be grave fissures of the neck of the w^omb or
perineal rupture, I prefer to have these relieved at
once if the patient be in a moderately good state,
but if the case be one of extreme feebleness, I like
to delay all surgical intervention until the improved
conditions w^hich follow my treatment offer a better
chance of successful mechanical interference. If
the patient be a virgin, and there seems little reason
to suspect misplacements, I trust again to the gen-
eral treatment. If, moreover, there be plain evidence
of misplacement, and the patient be of that tempera-
ment which makes vaginal examinations disastrous
shocks to the nervous system, I wait patiently the
result of the rest and its aids. Then, at the close of
two months I like to make an effort at local relief,
in the hope that with a reinforced nutritive life my
patient may bear the strain. Dr. Goodell will re-
member cases, seen with me, in which the patient,
having retroversion, decided to undergo no mechani-
cal treatment, and has seemingly become and re-
mained well, under rest, etc., despite the uterine
trouble.

Misplaced ovaries cause in my experience a great
deal of trouble, but both Prof. Goodell and I have
seen a number of cases in which this annoying com-

274 DISEASES OF THE NERVOUS SYSTEM.

plication righted itself spontaneously during treat-
ment by rest. In one of these cases, the misplace-
ment was so extreme and the symptoms caused by
it so grave that the propriety of double ovariotomy
was more than once discussed. We were pleasura-
bly surprised as the treatment progressed to find a
gradual slipping upwards of the ovaries until at
last they regained their usual place. This change ac-
companied a remarkable gain in vigor and in flesh.
I have never yet been able to make clear to myself
precisely why under these circumstances the ovaries
should be drawn up, but Prof. Groodell's opinion in a
matter of this kind must be far better than mine, and
as he thinks there is a competent physical explanation ,
I give his remarks in full : " The ovaries should be
daily replaced by atmospheric pressure, the knee-
breast posture, and the result is that they finally go
up to stay up. Under the influence of the general
gain in health, and the local handling of the mas-
seuse, the organs cease to be congested. Then the
increased deposit of fat in the abdominal walls, in
the omental apron, and around the abdominal vis-
cera, to say nothing of the needful fat-padding in
all the pelvic nooks and crannies, increases the re-
tentive power of the abdomen.^"

" By its gravity the now fat-laden and overhang-
ing wall of the abdomen tends to draw toward itself,
that is to say upward, the movable wall of the pelvis.
The behavior is like that of a half-filled India-rubber
ball, in which bulging at one portion causes a corre-
sponding cupping at another."

^ Lessons on Gynecology, Goodell, p. 116.

TREATMENT BY SECLUSION, REST, ETC. 275

You are now ready to put your patient at rest in
bed, and you will not, I trust, despise any details
which will make rest endurable and useful. You
cannot always get, but you can desire to get, sun-
shine, an open fireplace, a well-made bed, and a
lounge for change.

Rest means with me a good deal more than merely
sajdng '^ Go to bed and stay there." It means care
that letters bring no worrying news, that they are
brief and of such kind as a nurse may read aloud.
It means absence of all possible use of brain and
body. It means neither reading nor writing, at
least for a time, with exceptions in cases where, as
is rare, there is no asthenopia. If the nurse can
read to the patient, and reading be borne without
fatigue, let it be used at first for only a few minutes
at a time. If this wearies, then let the nurse try to
cull the bits of interesting news from the papers,
and as she glances over the columns talk this to the
patient instead of formally reading aloud. Why
this tires less than reading I do not know, but that
it does so I am sure. If you are disposed to smile
because I say let the nurse feed the patient, you will
not, if, lying supine, you make the experiment of
using your own hands in this act of feeding. Or
even if seated in bed you do this, you will find that
the eflbrt is singularly tiresome. I believe I have
done something to make rest fashionable among
physicians as an essential in the treatment of spinal
maladies, and both in them and in the treatment of
neurasthenia and hysteria it is well that you clearly
comprehend what it is that I mean by rest. Your

276 DISEASES OF THE NERVOUS SYSTEM.

trouble will be always that the patient will desire to
lie on a sofa, or to make some such compromise,
but in bad cases, and it is onh^ of these I speak, all
this is but mere trifling, and you had better, on the
whole, make an error in the direction of a too abso-
lute rest.

The moral uses of enforced rest are readily esti-
mated. From a restless life of irregular hours,
from hurtful sympathy and over-zealous care, the
patient passes into an atmosphere of quiet, of
orderly control, and under the care of a thorough
nurse. The result is always at first, whatever it
may be afterwards, a sense of relief, and a remark-
able and often a quite abrupt disappearance of many
of the nervous symptoms which had previously
harassed the patient. With this first sense of ease
comes the precious chance of the doctor for moral
medication. He can now point out that, however
hard it was with failing powers to control emotion
and suppress nervousness, it is easy to do all this
when the physical condition is improving. This
doctrine will be aided and enforced by the nurse if
a good one, and your patient will be constantly re-
minded that she is getting better physically, and is
expected to accomplish more and more in the way
of self-restraint. If she fails, you praise the efiPort.
If she succeeds, you applaud the success. You are
her whole audience, and this with a hysterical girl
gives you great power. Why rest is of therapeutic
value I have elsewhere more fully shown. It is of
more use here to urge that, like all medication, it
has its evil side, and that it is to the other parts of

TREATMENT BY SECLUSION, REST, ETC. 277

this system we must look for the means of over-
coming and counteracting them. Ordinarily, pro-
longed rest enfeebles circulation, weakens digestion,
lessens appetite, and constipates the bowels. Mus-
cles in action serve practically as small hearts for
themselves and the localities about them. Imagine
their activity suppressed for a time, and remember,
too, that the heart in a person at rest loses twenty
beats a minute, and thus adds to the passive mischief.
Moreover, the liver and the double abdominal circu-
lation, and the moving bowels cease to have the
constant stimulation which they get when we are
afoot, and so in many ways damage is done. Rest
then is, or may be, hurtful. We turn to massage and
electricity for aid in correcting this. Massage, or
kneading of the muscles, has been long used in
Europe and the East. It is the "shampooing" of
the Oriental, the " lammi lammi " of the Sandwich
Islander. I do not know that it has been used except
under my orders as a systematic daily mechanical
tonic. For details of just how it ought to be done,
and with what caution, and how long and what are
the immediate physiological effects, I must again
refer to my book on the " Treatment of ]!^eurasthenia
and Hysteria." Used daily, from half an hour to an
hour, it is a pleasant and refreshing process, and
even when, as does happen, it seems at first to tire,
all of this result, soon or late, passes away.

It substitutes exercise for exertion, and does nearly
all that a moderate amount of active muscular mo-
tion can do in the way of warming the limbs,
increasing the blood-flow, stimulating the local cir-

24

278 DISEASES OF THE NERVOUS SYSTEM.

culatioiis, and reddening the skin. It may, and
should, at last, be a pretty violent influence, and,
by and by, may be used in such a way as to jog the
intestines like the invaluable shaking given by a
rough trotting horse. To be thoroughly done, it
needs a trained masseuse, but any clever person,
who is strong enough, may easily learn to do it;
and it enables one daily to rub into the skin a large
amount of some nourishing oil, like that of the olive
or the cocoanut. You will meet with some difficulty
in having the back kneaded when there is spinal irri-
tation, but as to this you must be relentless ; and the
masseuse, by degrees approaching the sore spots, will
in time come to treat them as thoroughly as any other
part, and with the sure result of, by and by, lessening
and destroying the local sensitiveness. In like man-
ner, the hypereesthesias of other regions may be dealt
with, and, above all, that which is sometimes a truly
ovarian, and sometimes merely an abdominal surface
sensitiveness, may, with time and cautious patience,
be relieved or cured.

I never could see Avhy a tonic so valuable as this
should be left to assist the triumphs of the charlatan ;
and I feel' that, in making it of easy use, I have done
that which, in many ways, is valuable to the surgeon
and the physician.

Massage is, in these cases, absolutely essential;
electricity is very desirable; but we can, in man}'
cases, do without it.

It involves the daily use of induction-currents
(slow interruptions) to almost every muscle which
can be reached; the object being to throw each

TREATMENT BY SECLUSION, REST, ETC. 279

muscle into decided contraction. Finally, a mild
current with rapid breaks should be made to pass
from the neck to the feet for fifteen minutes. That
it is, thus used, a powerful tonic I have not the
faintest doubt, and I commonly employ it with
massage, except where the need to save expense is of
moment.

These means are valuable to prevent rest from
being hurtful, and to enable us to fatten and redden
the patient by a methodical system of over-feeding,
with the use of proper tonics. I have already said
that there is some trouble in treating fat and anaemic
women. You may cure them by ordinary means,
but it is easiest and safest to do so by putting them
at rest, and under-feeding with milk, so as, at first,
materially to reduce the flesh, after which the patient
may be subjected to the usual treatment by massage
and the other means I have detailed. It is easy,
with perfect security, to lessen the fat rapidly, if
only the patient be kept in bed; otherwise, as we
have too well known, it is a dangerous and difiicult
thing to effect. I may add that if there is much, or
a very obstinate dyspepsia, it is well to begin the
treatment of any case by Carel's milk treatment.
It is astonishing how this simplifies matters, and how^
often under milk, massage, and rest the whole train
of nervous ills melts away in a few^ days : and how
we are able to dispense with chloral and morphia, or
habitual use of other drugs. Indeed I may add that
I should be sorry, now-a-days, to treat any old case
of the opium habit without these invaluable aids.^

I Am. Journ. Med. Sci., Oct. 1866.

280 DISEASES OF THE NERVOUS SYSTEM.

In fact, if I have the least doubt, I never fail to
begin treatment bj rest, with milk as the sole diet.;
while, of course, there are also many cases where it
is used only as an adjuvant, and I simply feed the
patient in the ordinary manner. By some such
plan the patient has the diet gradually increased,
until it is common to see her take three meals as
well as two quarts of milk, six to nine ounces of
Hoff's fluid malt, and a variable amount of raw
soup between meals and at bed- time.

Iron in large doses, alcohol rarely, and cod-liver
oil, by the mouth or rectum, when well borne, are to
be added as indicated.

The result of two months of such treatment, in
pale, bloodless, meagre, and nervous women, must
be seen to be believed or duly appreciated. You
have seen it here often enough to understand me
fully. Each and all of the means described are to be
slowly and by degrees laid aside, and then you have
as carefully to get your patient up and afoot. Of
late, I have been in the habit of preparing for this
by allowing the nurse or masseuse to exercise the
patient, while in bed, with a series of slowly executed
Swedish gymnastics, which are' continued in a modi-
fied form, when the patient gets up. If this be well
and pleasantly managed, it is both agreeable to the
patient and a valuable means of training the muscles.

I have elsewhere shown that massage is followed
by an increase in the rate of elimination, and more
recently Dr. Peter Alexander Young ^ has published
analyses of great interest, which prove the immense

1 Edin. Clin, and Path. Joum., August, 1884.

TREATMENT BY SECLUSION, REST, ETC. 281

dailj*increase in the secretion of urea during rest
treatment. He'says : " The kidneys might be ex-
pected to suffer under the strain of the elimination
of the enormously increased quantity of urea, but
I have not found this to be the case. I have esti-
mated the quantity of urea passed in twenty-four
hours, and find it'was as follows:

Day of
Treatment.

1st

5th

10th

15th

20th

25th

30th

35th

89th

Day of
Treatment.

1st
3d
5th
10th
20th
30th
40th

FIRST

CASE.

Grs. of Urea in

Ozs. of Urin

24 hours.

24 hours.

. 220

16

221

28

639

53

602

50

823

64

770

64

746

62

722

60

. 607

62

SECOND CASE.

Gr.s. of Urea in

Ozs. of Urin

2-1: ]u)urs.

24 hours

. 141

10

274

16

278

20

420

30

520

38

575

42

875

68

"• That this largely increased quantity of urea was
chiefly derived from the nitrogenous food taken, and
not from the muscular waste, would be anticipated

24*

282 DISEASES OF THE NERVOUS SYSTEM.

from the researches of Fick and Wislicenus and
others. I found, in the first case, that on the four-
teenth day after the usual full diet and three hours'
massage, with thirty-five minutes' electricity, the
urea amounted to 650 grains in twenty-four hours,
and on the seventeenth day, after three days' cessa-
tion from rubbing and electricity, with the same
diet, the urea passed was 698 grains in twenty-four
hours."

Dr. Wm. W. Keen has recently shown that in a
case of albuminuria where the albumen disappeared
entirely with rest and reappeared with exercise, the
most extreme massage had no such influence as
physical exertion. This curious and interesting fact
suggests to us that the difference between exercise
and massage must be far greater than has been sup-
posed, and that probably the latter does not raise the
blood-pressure as does the former.

The final results of all this treatment when it suc-
ceeds are reasonably to increase the bulk of the
body, to improve the moral and physical tone, and
to cure the anaemia. These changes are obvious in
some degree early in the case, the flesh shows first
in the face, and the gain in blood in the pink of the
finger-nail, which I am apt to watch and note. I
have been many times asked if these amendments
or cures are permanent, and I believe I am now,
after a careful review of some hundreds of cases,
fully able to say that they are quite as lasting as the
cures of any nutritive defects obtained in more ordi-
narj? ways. It is a plan never, in my opinion^ to he used
where exercise, outdoor life, tonics, or change have not

TREATMENT BY SECLUSION, REST, ETC. 283

been thoroughly tested; but where these have failed it
leaves us with a novel resource without which no
case of broken constitution, nervousness, or old hys-
teria should be left to hopeless invalidism, and to a
life in bed, or on a lounge. I never use it if I can
do without it; but in well-chosen cases I use it with
a confidence which has become alike courageous and
habitual.

INDEX.

ALBUMINUEIA, effects of
J\ massage in, 282
Alternate spasms, 127
Anal spasm, 262
Anaemia with excess of fat, 268
Anaesthesia of rectum, 258
Anorexia, hysterical, 242
Aphonia, hysterical, forms of,

208, 211
Ataxia, hysterical, 39

description of, 40-43
of one limb, 48
of respiration, 215
treatment of, 45
Athetosis, hysterical, 110
Atropine, injection of, 109
Autobiography of hysteria, 88

IIRIQUET'S ataxia, 39

CASE of excessive fasting, 244
of hysteria with organic dis-
ease of spine, 228
of hysterical joint with extra-
capsular organic changes,
220
of irritable rectum, 255
of paralysis of rectum, 260
of rapid respiration from
wound of chest, 201
Chorea of childhood, 137
deaths from, 151
Gerhard on, 138
in Chicago, 151

Chorea in the black, 151
in Philadelphia, 151
mimicry of, 74
recurrence of, 146
relation of, to climate, 148
to locality, 150
to palpitation, 149
to weather, 144
season of, 138
varieties of, 154
Choreal habit, 156
Chronic spasms, 123
Coeducation, defects of, 14
Constipation, incoordination a

cause of, 261
Crutch cane, 47

DEFECATION in hysteria,
252
Deglutition in hysteria, 240
Diarrhoea, scybalous, 253

PLECTKICITY, 278
Vj Emotion, defects of, in hys-
terical paralysis, 35
Epidemic imitative chorea, 75

FASTING, excessive, 244
simulation of, 91

GOODELL on ovarian displace-
ment, 274

286

INDEX.

HABIT, chorea, 156
treatment of, 162
Hirsch on relation of chorea to

climate, 148
Hemiplegia, crutch for, 48
hysterical, 24
double, 31
Hunter, effects of attention on

body, 60
Hysteria, aphonia of, 208
ataxia of, 39
autobiography of, 88
causes of, 14
death in, 23

defects of sensation in, 26
deglutition in, 240
forms of, in America, 239
gastro-intestinal disorders of,

238
heart in, 185
hemiplegia of, 24
oedema of, 28
of the joints, 218 '

with organic changes,
225
paralysis of, 13
paraplegia of, 17
ptosis of, 134
pulse in, 190
reflexes in, 26-27
respiration in, 199
respiratory, ataxia of, 215
treatment of, 265
vaso-motor, disorders of, 184,

191
with organic disease of spine,
227
Hysterical anorexia, 242
ischsemia, 192
paresis, 50
regurgitation, 241

TNCOOKDINATION, a cause
X of constipation, 261
Imitation, unconscious, 62
Imitative chorea, epidemic of,

75
Ischaemia, hysterical, 192
in organic analgesia, 193

J

OINTS, hysterical, 218

K

EEN, Wm. W., 282

LEWIS, Morris J., chorea, 139
Local spasms, section of ten-
dons in, 128

MASSAGE, 277
effects of, in albuminuria,
282
Milk, use of, 279
Mills, chorea, 139
Mimicry of chorea, 74
of disease, 55
causes of, 56

VTERVOUSNESS, cardiac, 187
li general, 57
Night palsy, 182

rpDEMA, hysterical, 28

vXj GEsophageal vomiting in

hysteria, 240
Ovaries, displacement of, 273
Ovarian hysteria, ovarian ten-
derness in, 27

PAGET, Sir James, mimicry of
disease, 55
effects of attention on body,
60
Pain, relation of, to weather, 145
Paralyses of hysteria, treatment
of, 20
hysterical, 13

electrical reactions in,
28
of childhood, [^relation ^ to

weather, 146
of rectum, 256-259
Paraplegia, hysterical, 17

INDEX,

287

Paresis of hysteria, 60
Phantom tumors, 108
Ptosis, hysterica], 134

RACE, relation of, to chorea,
151
Rectal pain, 262
Rectum, anaesthesia of, 258
in hysteria, 252
paralysis of, 256-259
the irritable, 254
Reflexes in hysterical paralysis,

26-27
Regurgitation in hysteria, 241
Respiratory disorders of hysteria,
199
failure, sleep, 183
Rest, 275

treatment, secretion of urea
during, 281
Rufz on relation of chorea to
climate, 148

S CHAFFER on mimicry of
disease, 55
Seclusion, 270
Secretion of urea during rest

treatment, 281
Sensation, defects of, in hysteria,

26
Sensory discharges, aura of, 171
forms of, 167
in sleep, 163
treatment of, 171
Simulation of fasting, 91
Sinkler Wharton, paralysis of

childhood, 146
Skey, on mimicry of disease, 55
Sleep, disorders of, 163

failure of respiratory centres,
183

Sleep, hemiplegia of, 181

local spasms in, 180

sensory discharges in, 163
Spasms, alternate, 127

athetoic, 110

chronic, 123

functional, 103

local, of great pectoral mus-
cle, 107

of anus, 262

permanent, 124

simulation of, 130

rotatory, 97

rhythmical, of gastrocne-
mius, 109

unusual forms of, 96

TABLES of chorea, 140
Tendons, section of, 128
Treatment of gastro-intestinal
disorders in hysteria, 243
of hysteria, 265
of hysterical rectum, 256
Tumor, 114

emotional, 115
forms of, 117
phantom, 108
Tremors, alcoholic, 121
local, 119

TTTERUS,

in hysteria, 272

YASO-MOTOR disorders in
V hysteria, 184
Vomiting, hysterical, 82

imitative, 63

oesophageal, 240
Von Ziemssen on relation of
chorea to climate, 148

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A SHHURST (JOHN, Jr.) THE PRINCIPLES AND PRACTICE OP
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ALL (CHARLES B.) DISEASES OF THE RECTUM AND ANUS.
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IDLOXAM (C. L.) CHEMISTRY, INORGANIC AND ORGANIC.

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PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN

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QENTURY OF AMERICAN MEDICINE.— A History op Medicine in
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HHAMBERS (T. K.) A MANUAL OF DIET IN HEALTH AND
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HLASSEN'S QUANTITATIVE ANALYSIS. Translated by Edgar F.
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pOOPER(B.B.) LECTURES ON THE PRINCIPLES ANDPRACTICE
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pOENIL (V.) SYPHILIS: ITS MORBID ANATOMY, DIAGNOSIS
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pORNIL (V,), AND RANVIER (L.) MANUAL OF PATHOLOGICAL
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nULLEKIER (A.) AN ATLAS OF VENEREAL DISEASES. Trans-
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^LTON (JOHN C ) DOCTRINES OF THE CIRCULATION OF
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A TREATISE ON HUMAN PHYSIOLOGY. Sevanth edition,

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THE TOPOGRAPHICAL ANATOMY OF THE BRAIN. In

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three quarto volumes containing 178 pages of text, with 48 full page
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hMK (JAMES D.) THE STRUCTURE AND CLASSIFICATION OF
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ELA BECHE'S GEOLOGICAL OBSERVER. In one large 8vo. vol.
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■nTJJARDIN-BEAUMETZ. DICTIONARY OP THERAPEUTICS,
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TJUNGLISON (ROBLEY). MEDICAL LEXICON,- A Dictionary of
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pDIS (ARTHUR W.) DISEASES OF WOMEN. A Manual for Stu-
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■pLLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY.
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pMMET (THOMAS ADDIS). THE PRINCIPLES AND PRACTICE
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pARQTJHARSON (ROBERT) A GUIDE TO THERAPEUTICS.
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"PINLAYSON (JAMES). CLINICAL DIAGNOSIS. A Handbook for
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pLINT (A.TJSTIN). A TREATISE ON THE PRINCIPLES AND
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AMANUALOF AUSCULTATION AND PERCUSSION; of the

Physical Diagnosis of Diseases of the Lungs and Heart, and of Tho-
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A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREAT-
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CLINICAL MEDICINE. A SYSTEMATIC TREATISE ON

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pLINT (AUSTIN). MEDICAL ESSAYS. In one 12mo. vol., pp. 210.

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ON PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, etc.,

a series of Clinical Lectures. In one 8vo. volume of 442 pages.

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THE PHYSICAL EXPLORATION OP THE LUNGS, BY

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pOLSOM (C. F.) An Abstract of Statutes of U. S. on Custody of the
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pOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New
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A TEXT-BOOK OF PHYSIOLOGY. English Student's edition.

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pOTHERGILL'S PRACTITIONER'S HANDBOOK OF TREATMENT.
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paWNES(GEOKGE). A MANUALOF ELEMENTARYCHEMISTRY.
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pox (TILBURY) and T. COLCOTT. EPITOME OF SKIN DIS-
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iR iHKLAND (E.) and JAPP (F. R.) INORGANIC CHEMISTRY.
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pULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR
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nOULD (A. PEARJE). SURGICAL DIAGNOSIS. In one 12mo.
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piBSON'S INSTITUTES AND PRACTICE OF SURGERY. In two
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QLUGE (GOTTLIEB). ATLAS OF PATHOLOGICAL HISTOLOGY.
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riRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL.
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n KEEN (T. HENSY) . AN INTRODUCTION TO PATHOLOGY AN D
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A PRACTICAL TREATISE ON THE DISEASES, INJU-

ries and Malformations of the Urinary Bladder, the Prostate Gland
and the Urethra. Third edition, thoroughly revised and much
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A PRACTICAL TREATISE ON FOREIGN BODIES IN THE

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IJAMILTON (ALLAN McLANE). NERVOUS DISEASES, THEIR
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TTAMILTON (FRANK H.) A PRACTICAL TREATISE ON FRAC-
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TTARTSHORNS (HENRY). ESSENTIALS OF THE PRINCIPLES
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A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one

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A CONSPECTUS OF THE MEDICAL SCIENCES. Com-
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TJEEMANN (L.) EXPERIMENTAL PHARMACOLOGY. A Hand-
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TJILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DIS-

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TTILLIEB, (THOMAS). A HANDBOOK OF SKIN DISEASES. 2d ed.

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RC
3liO

M69
1885

V J DT7 t>r\r-i ly <.